Inquest into the Death of John Henry WATERFALL

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

1. 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
2. Addition of mandatory fields to EMRA, PMRA, and OMI to record terminal illness status and whether prisoner is being transported for palliative care
3. 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
4. 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
5. Review of Ventia's Standard Operating Procedure and risk assessment forms to align with above changes
6. Prioritisation and completion of consultation and approval process for proposed changes as a matter of urgency