Inquest into the Death of Jamie Frederick GINN
Deceased
GINN, JAMIE FREDERICK
Demographics
50y, male
Date of death
2023-10-10
Finding date
2025-12-17
Cause of death
cocaine toxicity
AI-generated summary
Jamie Frederick Ginn, 50, died from cocaine toxicity on 10 October 2023 while in custody at Perth Watch House (PWH). He had ingested approximately one teaspoon of cocaine hydrochloride; the coroner could not determine when or how despite exhaustive investigation. Seizures began at 6:38 pm and were discovered by PAO Skulley at 6:53 pm. CPR commenced at 7:15 pm and extensive resuscitation was undertaken, but he was declared dead at 8:05 pm. Death was ruled accidental with no evidence of third-party involvement. The coroner found the standard of supervision poor: the Cells Control Officer failed to detect Mr Ginn's 15-minute seizure via CCTV monitoring due to multitasking with data entry. However, the coroner could not prove this failure caused or contributed to death, as the cocaine levels were deemed unsurvivable even with perfect health. Seven recommendations were made to improve PWH security and supervision.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- ingestion of fatal amount of cocaine (mechanism and timing unclear)
- dilated cardiomyopathy from anabolic steroid use
- coronary artery disease
- inadequate CCTV supervision—15-minute delay in detecting medical event
- cocaine levels unsurvivable even with healthy cardiovascular system
Coroner's recommendations
- Ensure all Perth Watch House personnel are aware of checklist for death or serious incident to preserve scene integrity, particularly regarding seizure of items for analysis
- Conduct review of staffing levels at Perth Watch House to determine if number of cells officers allocated per shift is sufficient
- Conduct review of Cells Control Officer role to determine whether it should be split between two PAOs—one solely responsible for CCTV monitoring, another for data entry and other tasks, with regular role swapping every two hours or other suitable interval
- Review procedures for basic and strip searches at Perth Watch House to enhance detection of concealed items including illicit drugs, and ensure staff familiarity with policies
- Consider requiring all detainees to pass through body scanner on admission to Perth Watch House
- Review close circuit television cameras and monitoring equipment at Perth Watch House; consider multiple cameras per cell, radar-sensing technology, artificial intelligence algorithms to detect unusual behaviour, biometric monitoring systems, and body-worn cameras for staff
- Conduct review to determine whether number of registered nurses available on each shift at Perth Watch House is sufficient and whether current 12-hour shift length is appropriate
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