Coronial
WAother

Inquest into the Death of Robert Fredrick PARNELL

Deceased

Robert Fredrick PARNELL

Demographics

29y, male

Coroner

Coroner Jenkin

Date of death

2022-05-16

Finding date

2024-09-05

Cause of death

butane and propane toxicity from inhalation of canola oil spray propellants

AI-generated summary

Robert Parnell, aged 29, died from butane and propane toxicity after inhaling propellants from a can of canola oil spray in a prison kitchen toilet. He had a long history of polysubstance use including solvent sniffing dating to age 13. Working as a kitchen cleaner at Albany Regional Prison, he accessed canola spray cans freely stored in an unsecured storeroom. He inhaled the propellants using a plastic bag, lost consciousness, struck his head on a tap during collapse, and could not be revived despite CPR and resuscitation efforts. The coroner found supervision sub-standard, noting aerosol cans should have been restricted given Robert's known history of substance abuse and the severe cardiac risks of butane inhalation (sudden sniffing death from arrhythmia). The Department had not adequately screened prisoners for kitchen work or controlled access to hazardous aerosols despite knowing the risks.

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

Specialties

forensic medicineemergency medicinetoxicologyoccupational and environmental health

Error types

systemsupervision

Drugs involved

butanepropanenaloxone

Clinical conditions

volatile substance abusebutane toxicitypropane toxicitycardiac arrhythmiahypoxiasudden sniffing deathhead trauma

Procedures

cardiopulmonary resuscitation

Contributing factors

  • unrestricted prisoner access to aerosol cans in kitchen storeroom
  • lack of prisoner screening for kitchen work assignments
  • failure to recognise or manage known history of solvent sniffing
  • inadequate supervision in kitchen area with unsecured storerooms
  • loss of consciousness and head trauma during inhalation episode
  • delayed emergency response time

Coroner's recommendations

  1. Discontinue use of aerosol cooking oil spray in custodial facilities by 30 September 2024 and replace with pump spray bottles
  2. Discontinue use of any other aerosol cans that prisoners have direct access to and which may be misused to cause harm by 30 September 2024
  3. Restrict access to aerosol cans necessary for prison industries to secure storage accessible only by staff, for use by prisoners under strict supervision
  4. Implement screening procedures for prisoner kitchen work assignments, particularly for prisoners with known history of substance abuse or solvent sniffing
  5. Improve supervision protocols in kitchen storerooms and restrict prisoner access to hazardous materials
  6. Install emergency-access cubicle door systems in prison facilities (already implemented post-death)
Full text
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Source and disclaimer

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