Coronial
WAhospital

Inquest into the Death of Henry ALLEN

Deceased

Henry ALLEN

Demographics

60y, male

Coroner

Deputy State Coroner Linton

Date of death

2020-06-14

Finding date

2022-08-02

Cause of death

sepsis and aspiration pneumonia in a man with oral squamous cell carcinoma and multiple comorbidities, with terminal palliation

AI-generated summary

Henry Allen, a 60-year-old man with oral squamous cell carcinoma, lung cancer, and multiple comorbidities died from sepsis and aspiration pneumonia while in prison custody at Fiona Stanley Hospital. He received appropriate medical care including chemotherapy, radiotherapy, surgery, and palliative care. Cancer recurred in March 2020 despite 19 months remission; COVID-19 disruptions limited treatment options. A PEG feeding tube was inserted for nutrition. The coroner found care standards were good overall but identified a procedural failure: the Department of Justice did not initiate Royal Prerogative of Mercy consideration when Mr Allen's terminally ill status escalated, though early release was considered unlikely. The coroner recommended amending policy to include specific procedures for terminally ill prisoners under continuing detention orders.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

oncologypalliative careradiation oncologysurgeryemergency medicinegeriatric medicinedentistryophthalmologyphysiotherapy

Error types

systemdelay

Drugs involved

oxycodonebuprenorphinelidocaineantibioticsintravenous fluids

Clinical conditions

oral squamous cell carcinomalung adenocarcinomasepsisaspiration pneumoniabacteraemiadiabetes mellitushypertensionhypercholesterolaemiagastro-oesophageal reflux diseaseischaemic heart diseasedysphagia

Procedures

chemotherapyradiotherapysurgerylymph node resectionpercutaneous endoscopic gastrostomy (PEG) insertionexternal post-mortem examination

Contributing factors

  • oral squamous cell carcinoma with recurrence
  • lung adenocarcinoma
  • aspiration pneumonia
  • bacteraemia
  • multiple comorbidities including diabetes, hypertension, ischaemic heart disease
  • continued smoking after cancer diagnosis
  • COVID-19 pandemic disruptions to treatment
  • difficulty swallowing due to tumour mass
  • prisoner non-compliance with some treatments
  • procedural failure regarding Royal Prerogative of Mercy consideration

Coroner's recommendations

  1. Amend Commissioner's Operating Policy and Procedure 6.2 (COPP 6.2) to include specific procedures for when a prisoner subject to a continuing detention order is terminally ill, to facilitate early review by the Supreme Court of changed circumstances and consideration for early release where appropriate
Full text

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.