Coronial
WAprison

Inquest into the Death of William Frederick ANDERSON

Deceased

William Frederick ANDERSON

Demographics

53y, male

Coroner

Deputy State Coroner Linton

Date of death

2020-12-24

Finding date

2022-12-13

Cause of death

intracerebral haemorrhage

AI-generated summary

William Anderson, an Aboriginal man aged 53, suffered a catastrophic intracerebral haemorrhage while imprisoned and died despite timely emergency response. Multiple delays occurred: 25 minutes before the cell was opened, 20 minutes before ambulance was called, and 34 minutes before departure from prison. Expert evidence confirmed the massive brain bleed was unsurvivable regardless of timing. However, the case identified important systemic failures in medical emergency protocols at the prison, particularly inadequate training of night shift officers in emergency response and first aid. Recommendations focus on ensuring prison officers understand that life preservation supersedes paperwork delays, maintaining current First Aid qualifications, developing formal Senior Officer training, and implementing scenario-based medical emergency training.

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

Specialties

emergency medicineneurologyneurosurgeryforensic medicine

Error types

delaysystemcommunication

Drugs involved

aspirinclopidogrelmedications for diabetesmedications for hypertension

Clinical conditions

intracerebral haemorrhagehaemorrhagic strokehypertensiontype 2 diabetes mellitusalcohol use disordercoronary artery diseasecirrhosis

Contributing factors

  • hypertension
  • type 2 diabetes mellitus
  • heavy alcohol use and alcohol-related liver disease
  • coronary artery atherosclerosis
  • delay in opening cell
  • delay in calling ambulance
  • delay in ambulance departure from prison
  • communication failure between prison officers and ambulance staff regarding urgency

Coroner's recommendations

  1. Rephrase the Local Emergency Plan for Medical Emergency at the Eastern Goldfields Regional Prison to ensure officers understand that preservation of life supersedes completion of paperwork and that communication with ambulance medics regarding urgency is essential, rather than expecting them to volunteer this information unprompted.
  2. Department of Justice should prioritise ensuring all prison officers at the Eastern Goldfields Regional Prison are current in their First Aid Qualification, with first priority to Senior Officers, as they will be required to make decisions during medical emergencies when no health staff are available.
  3. Department of Justice should develop a formal online Senior Officer course to enable prison officers aspiring to supervisory roles to complete training at their own pace whilst learning practical aspects on the job.
Full text
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Source and disclaimer

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