Inquest into the Death of Herbert William MACKAY

Contributing factors

• metastatic adenocarcinoma lung cancer (stage 4)
• recurrent pleural effusions
• pericardial effusions
• probable infection of pleural/pericardial fluid
• cardiac compression from effusion during surgery
• PEA cardiac arrest intraoperatively
• advanced stage malignancy with rapid spread to chest cavity

Coroner's recommendations

1. Development of communication strategies and information materials between prison and hospital facilities to improve awareness of prison infirmary capacity and limitations, including preparation of an information flyer addressing limitations of post-discharge prison care, non-hospital environment status, custodial restrictions, available therapies, and contact details for liaison
2. Continued implementation and rollout of smoke-free prison policy across all Western Australian prison sites by end of 2024, with staged implementation, ongoing evaluation, educational resources, counselling support, and nicotine replacement therapy including consideration of free nicotine patches for prisoners
3. Review of the restraint removal process for hospitalised prisoners to make approval procedures faster while maintaining security considerations
4. Ensured recording of all discussions regarding smoking cessation and other health interventions with prisoners to improve documentation of clinical care
5. Continued implementation of updated COPP 6.2 procedures for management of terminally ill prisoners subject to Indefinite Detention Orders, including notification of State Solicitor's Office of medical condition