Coronial
WAother

Inquest into the Death of Lewis Walter WARD

Deceased

Lewis Walter Ward

Demographics

male

Date of death

2023-07-25

Finding date

2026-01-08

Cause of death

out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and Type 2 diabetes mellitus

AI-generated summary

Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smoker. In October 2021, prison doctors identified evidence of previous myocardial infarction on ECG and referred him for an exercise stress test. The appointment scheduled for February 2022 was missed, then erroneously marked as attended in hospital records, preventing prompt rescheduling. The error went undetected for 630 days until a new appointment was booked for 18 July 2023—two days after his collapse. Expert evidence suggested earlier testing may not have changed the outcome, as he was asymptomatic and already on appropriate cardiovascular medications. The coroner found this a 'missed opportunity' but not conclusively preventable. The Department subsequently implemented improved referral tracking systems.

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

Specialties

cardiologyemergency medicinegeneral medicinegeneral practiceintensive careparamedicineretrieval medicine

Error types

diagnosticsystemdelaycommunication

Clinical conditions

atherosclerotic cardiovascular diseasecoronary artery diseasemyocardial infarction (prior inferior)out-of-hospital cardiac arresttype 2 diabetes mellitushypertensiondyslipidaemiaischaemic heart disease

Procedures

cardiopulmonary resuscitationdefibrillationintubationelectrocardiographyexercise stress testechocardiographycomputed tomography brain scan

Contributing factors

  • atherosclerotic coronary artery disease with severe narrowing
  • myocardial infarction (prior inferior)
  • Type 2 diabetes mellitus
  • hypertension
  • dyslipidaemia
  • smoking

Coroner's recommendations

  1. Consider improving coverage of CCTV cameras over the football oval at West Kimberley Regional Prison
  2. Continue working towards introducing body-worn cameras in all prisons, including West Kimberley Regional Prison
Full text
Official source Archived copy

Related cases

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —