Inquest into the Death of John Henry WATERFALL
Deceased
John Henry WATERFALL
Demographics
76y, male
Date of death
2021-12-16
Finding date
2023-09-21
Cause of death
Bronchopneumonia with multiple organ failure in the setting of advanced metastatic prostatic adenosquamous carcinoma (medically palliated)
AI-generated summary
John Henry Waterfall, a 76-year-old prisoner at Acacia Prison, died from bronchopneumonia with multiple organ failure secondary to advanced metastatic prostate cancer. He received generally appropriate medical care during his incarceration, though he frequently declined investigations and treatment. The significant clinical and medicolegal issue was his inappropriate restraint during hospital transfer and admission despite clear Department of Justice policy exempting terminally ill, elderly, frail patients with mobility issues from restraints. An External Movement Risk Assessment incorrectly answered 'No' to medical objections to restraints. Restraints were removed only hours before death when his clinical deterioration was apparent. The coroner found no issues with his medical management otherwise, but strongly urged urgent implementation of proposed procedural changes to prevent recurrence.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Advanced metastatic prostate cancer with extensive spread
- Bilateral pneumonia with emphysema
- Multiple organ involvement (liver, adrenal glands, kidneys, bladder)
- Cervical spine metastases with likely pathological fracture
Coroner's recommendations
- Urgent implementation of proposed changes to DOJ's External Movement Risk Assessment (EMRA), Prisoner Movement Risk Assessment (PMRA), Offender Management Information (OMI), and Hospital Admittance Advice (HAA) forms to include palliative care as a reason for transfer and a checkbox for expected return to prison
- Addition of mandatory fields to EMRA, PMRA, and OMI to record terminal illness status and whether prisoner is being transported for palliative care
- Implementation of a terminal illness medical alert within the Total Offender Management Solution (TOMS) system visible to all users to assist identification of terminally ill prisoners and assessment of restraint requirements
- Amendment of COPP 12.3 Conducting Escorts to include Stage 3 and Stage 4 terminally ill prisoners in provision 5.3.1 to prohibit use of restraints
- Review of Ventia's Standard Operating Procedure and risk assessment forms to align with above changes
- Prioritisation and completion of consultation and approval process for proposed changes as a matter of urgency
Full text
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