Inquest into the Death of Ian HEAD

Contributing factors

• COVID-19 infection (second episode after previous recovery)
• chronic obstructive pulmonary disease
• hypertension
• chronic kidney disease (Stage 2 renal failure)
• non-reporting of diarrhoea symptoms to medical staff
• missed medical appointments in July-August 2022
• delayed scheduling of comprehensive medical review upon transfer to Acacia Prison
• low doctor-to-prisoner ratio at Acacia Prison
• failure to identify unresponsiveness during morning welfare check and cell unlock

Coroner's recommendations

1. Acacia Prison to complete the Department of Justice recommendation to amend Standing Order 10.2 (Daily Prison Routine and Populations Counts) to ensure population counts and welfare checks are appropriately performed and recorded, with emphasis on checking for prisoner movement and apparent good health
2. All prisons in Western Australia should aim to maintain a doctor-to-prisoner ratio of approximately one full-time GP to 250 patients to provide good patient care and safety
3. Consider whether current GP staffing levels at Acacia Prison are appropriate to meet the needs of the prison population, or alternatively, encourage nurse practitioners to take a more proactive role in assessing overall prisoner health status when opportunities present (e.g., during walk-in clinic visits)
4. Continue with Department's planned updates to Policy PM05 Deaths to include more detailed guidance for health staff (both doctors and registered nurses) on declaring life extinct, in alignment with Department of Health and WA Country Health Service policies, to clarify decision-making around resuscitation and acute collapses in the prison setting