Inquest into the Death of Edward Ivan AFRICH

Contributing factors

• emphysema not identified in initial prison assessment despite being documented by general practitioner
• health summary sheet from general practitioner not forwarded from Hakea to Acacia Prison
• failure to review health summary sheet that was available in electronic records
• placement in shared cell with multiple smokers for 9 months despite emphysema diagnosis
• failure to implement specific emphysema treatment at Casuarina Prison despite severe emphysema diagnosis in December 2018
• exposure to second-hand smoke in locked prison cell at night
• failure to complete risk assessment for restraint use when transferred to hospital
• continued use of restraints after hospital admission despite medical advice to remove them
• delayed removal of leg restraints despite haematologist request and terminal illness status

Coroner's recommendations

1. Encourage the Department to rapidly implement proposed redesign of requests for release of medical information to specifically ask for recent investigations, specialist letters, ECGs and imaging results
2. Ensure health summaries can be scanned directly into EcHO to bring them to the attention of relevant prison doctors in a timely manner
3. Continue implementation of templates for first medical assessments that include specific questions about lung disease and exercise tolerance to prompt disclosure of respiratory conditions
4. Continue transition of all prisons to smoke-free status (targeted completion December 2024), commencing with pilot at Bandyup Women's Prison in October 2022
5. Ensure updated policies and procedures regarding use of restraints for prisoners admitted to hospital for palliative care are fully complied with