Inquest into the Death of David John HATCHER
Deceased
David John Hatcher
Demographics
60y, male
Date of death
2024-09-27
Finding date
2026-04-01
Cause of death
Pulmonary tuberculosis in a man with chronic obstructive pulmonary disease, with terminal comfort care
AI-generated summary
David John Hatcher, aged 60, was a remand prisoner at Hakea who died at Fiona Stanley Hospital on 27 September 2024 from pulmonary tuberculosis superimposed on severe chronic obstructive pulmonary disease. He was hospitalized for 109 days across two admissions. In May 2024, he was diagnosed with active TB and received a four-drug treatment regime. Readmitted in June 2024 with multi-organ sepsis and acute kidney injury, he required intensive care. Despite comprehensive care from multiple specialist teams (Respiratory Medicine, Infectious Diseases, Mental Health), he could not overcome his terminal illness. Key factors in his death included TB on a background of extensive pre-existing lung damage, significant malnutrition (he declined nutritional support initially), and low mood affecting engagement with treatment. The coroner found excellent clinical care but identified non-compliant application of restraints on two occasions, recommending TOMS system improvements for recording terminally ill status and better restraint policy compliance.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Active pulmonary tuberculosis occurring on background of severe chronic obstructive pulmonary disease with extensive lung damage
- Significant malnutrition and being underweight
- Declined nutritional intervention including nasogastric tube until late in illness
- Low mood and depression affecting engagement with treatment
- Multi-organ sepsis
- Acute kidney injury
- Immunocompromised state from TB infection
Coroner's recommendations
- Upgrade TOMS Medical Status module to automatically populate prisoner's terminally ill status across other modules and sections of the system to prompt consideration of need for External Movement Risk Assessment if restraints are to be applied (target date 30 June 2026)
- Create interface on TOMS between Terminally Ill list and Offender Movement Information to ensure terminally ill status is reflected when prisoners are transferred to hospital
- Improve recording and awareness of prisoners' terminally ill status among both health services and custodial staff
- Continue implementation of system improvements to ensure compliance with restraint policies for terminally ill prisoners
- Consider whether restraint oversight reviews should be conducted by Operations Centre (available 24/7) rather than Operational Compliance Team (weekdays only)
Full text
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