Inquest into the Death of Errol Warren BARTLETT

Contributing factors

• Non-disclosure of elevated PSA reading to prison health services
• Delayed diagnosis of prostate cancer until advanced metastatic stage
• Failure to complete risk assessment prior to applying restraints during hospital transfer
• Inappropriate use of restraints on terminally ill, elderly, frail prisoner at hospital
• Discharge from acute hospital to prison infirmary rather than direct palliative care

Coroner's recommendations

1. When a prisoner is escorted to a hospital for palliative treatment only, the documentation provided to the officers responsible for the hospital sit should clearly specify that the prisoner is to receive palliative care and is not expected to be returned to prison.
2. The Department should ensure that a one-page document accompanying prisoners attending hospitals clearly outlines the limited services available at the prison infirmary and, in appropriate cases, clarifies that palliative medical care is not available at any Western Australian prison apart from the infirmary at Casuarina, and that facilities at Casuarina for palliative care are not ideal.
3. General practitioners should include recent investigations, imaging, ECGs and other pathology in prisoner health summaries (noting the Department is redesigning its request for medical information to include a specific box for this information).
4. Documented External Movement Risk Assessments (EMRA) or Prisoner Movement Risk Assessments (PMRA) must be completed and approved by the superintendent prior to application of restraints on prisoners with significant medical and/or mobility issues, including all terminally ill prisoners.
5. Staff should ensure awareness and compliance with COPP 12.3 section 5.3 which prohibits restraints on prisoners with significant medical and/or mobility issues unless a documented risk assessment and superintendent approval is obtained.