Coronial
WAhospital

Inquest into the Death of Hugh WARD

Deceased

Hugh WARD

Demographics

89y, male

Coroner

Coroner Jenkin

Date of death

2021-10-05

Finding date

2023-03-30

Cause of death

Complications of cerebrovascular accident (stroke); specifically a catastrophic left-sided embolic stroke

AI-generated summary

Hugh Ward, an 89-year-old sentenced prisoner, died from complications of stroke following an embolic cerebrovascular accident at Sir Charles Gairdner Hospital. While incarcerated, Mr Ward had multiple comorbidities including atrial fibrillation, heart disease, diabetes, and dementia. A critical clinical challenge involved balancing anticoagulation therapy to prevent embolic stroke against his high gastrointestinal bleeding risk following gastric ulcers and his frequent falls. His anticoagulant (apixaban) was withheld from July 2021 onwards due to bleeding risk exceeding stroke risk. Medical care was considered thorough and compassionate. Key systemic issues included: failure to promptly record an Enduring Power of Guardianship in the medical record, leading to cancellation of a medically indicated gastroscopy in September 2020; and inadequate family communication about his medical condition despite valid written consents. Administrative gaps in information management between prison systems (TOMS) and medical records (EcHO) compromised care coordination and family involvement in his deteriorating condition.

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

Specialties

neurologycardiologygastroenterologypalliative careemergency medicinecorrectional health

Error types

communicationsystem

Drugs involved

warfarinapixaban

Clinical conditions

cerebrovascular accident (embolic stroke)atrial fibrillationheart diseasetype 2 diabetesgastric ulcerssubarachnoid haemorrhagedementiacognitive impairment

Procedures

percutaneous thrombectomygastroscopyCT scanningcystoscopy

Contributing factors

  • Atrial fibrillation
  • Age (89 years)
  • Multiple comorbidities including heart disease and diabetes
  • Withholding of anticoagulation therapy due to high gastrointestinal bleeding risk
  • History of gastric ulcers
  • Multiple falls increasing bleeding risk
  • Previous embolic strokes
  • Failure to maintain anticoagulation to prevent clot formation

Coroner's recommendations

  1. When a prisoner is received into custody, DOJ should consider asking the prisoner to provide written consent for their nominated next-of-kin to be provided with information about their medical condition and/or its management, particularly for prisoners likely to require ongoing medical treatment due to age, cognitive ability, and/or medical conditions
  2. DOJ should consider implementing a practice of including within the 'Medical Alert' tab on a prisoner's profile within the Total Offender Management Solutions system any information relating to the prisoner's consent to provide third parties with information about their medical condition and/or its management
  3. When a prisoner is subject to an enduring power of attorney or a guardianship order, DOJ should ensure that an alert is placed on the prisoner's profile within the Total Offender Management Solutions system to alert users to that fact, with such alerts placed immediately upon execution of the order
Full text
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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.

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