Inquest into the Death of Ronald Joseph BUCKLAND
Deceased
Ronald Joseph BUCKLAND
Demographics
70y, male
Date of death
2020-07-09
Finding date
2022-08-01
Cause of death
bronchopneumonia in a man with intra-abdominal carcinoma and multiple co-morbidities, with terminal palliative care
AI-generated summary
Ronald Joseph Buckland, aged 70, died in custody at Fiona Stanley Hospital from bronchopneumonia with intra-abdominal carcinoma and multiple comorbidities. A life-sentenced prisoner, he had extensive medical conditions including cardiac disease, liver cirrhosis, and COPD. Key clinical issues included: (1) unauthorised self-administration of oxygen from Oxiboots without medical supervision, which masked deterioration and delayed recognition of acute coronary syndrome; (2) repeated refusals of diagnostic investigations (colonoscopy/gastroscopy) for anaemia, delaying cancer diagnosis; (3) inadequate staff appreciation of risks from unmonitored oxygen use in angina management. The coroner found medical care exceeded community standards and was well-supervised. The prisoner's autonomy in refusing treatment was appropriately respected, and he was competent to make these decisions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- intra-abdominal carcinoma (adenocarcinoma of upper aero-digestive tract)
- coronary artery arteriosclerosis
- chronic obstructive pulmonary disease
- heart failure with previous coronary artery bypass grafts
- unauthorised unmonitored self-administration of oxygen from Oxiboots
- late diagnosis of abdominal cancer due to prisoner's refusal of diagnostic investigations
- inadequate staff awareness of risks associated with unmonitored oxygen use
- acute coronary syndrome episodes not recognised due to masked symptoms from self-oxygen use
Coroner's recommendations
- Clarification issued via Deputy Commissioner's Broadcast (29 July 2021) that Oxiboots were only to be used by clinical staff or those who had completed Advanced Resuscitation Techniques training, not by prisoners for self-administration
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