Coronial
WAhome

Inquest into the Death of Operation Lantana

Deceased

Sandra McCarty, Pia Bosso, Sandra Kokalis, Deborah Gruber, Carmelo Vinciullo (five deceased; Daryl Green and Antonio Ranieri died later, outside WA)

Date of death

2005-05 to 2005-07

Finding date

2012-06-29

Cause of death

Toxicity from intravenous caesium, DMSO, and other substances administered as part of unproven high pH cancer therapy; specific mechanisms included gastrointestinal hemorrhage with metabolic derangement (McCarty), caesium-induced cardiac arrhythmia (Bosso), gastrointestinal toxicity with metabolic derangement and sepsis (Kokalis and Gruber), metastatic cancer (Vinciullo after cessation of treatment)

AI-generated summary

In May 2005, the Kathi Preston Memorial Health Centre (KPMHC) operated an unproven cancer therapy clinic from Dr. Alexandra Boyd's home in Perth, Western Australia, administering intravenous treatment containing caesium, DMSO, and Laetrile under remote supervision of Dr. Helfried Sartori from Thailand. Seven cancer patients received treatment; four women (Sandra McCarty, Pia Bosso, Sandra Kokalis, and Deborah Gruber) died within four consecutive days (25-28 May 2005) from treatment toxicity before completing 12 days of therapy. The coroner found the treatment was scientifically unproven, extremely dangerous, and caused or significantly accelerated their deaths through metabolic derangement, gastrointestinal hemorrhage, cardiac arrhythmia, and sepsis. Patients and families were misled about risks and success rates. The clinic operated in substandard conditions with inadequate clinical supervision, sterile protocols, and monitoring. The coroner referred Dr. Boyd, nurses Phasey and Baker to AHPRA, and the matter to the Director of Public Prosecutions.

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

Specialties

general practiceoncologyintensive careemergency medicinepalliative care

Error types

diagnosticproceduralcommunicationsystemdelay

Drugs involved

caesium chloridedmsolaetrilevitamin cvitamin avitamin b12folic acidmagnesiumpotassium chloridetrace mineralsmorphine

Clinical conditions

metastatic breast carcinomametastatic thyroid carcinomametastatic colonic carcinomametastatic ewing's sarcomachronic lymphocytic leukaemiacaesium toxicitygastrointestinal haemorrhagemetabolic derangementhypercalcemiametabolic acidosiscardiac arrhythmiaventricular fibrillationsepsisinfection (staphylococcus aureus bacteremia from PICC line)seizuressevere dehydrationhepatic dysfunctioncyanide toxicity (from oral laetrile)

Procedures

peripheral inserted central catheter (picc line) insertionintravenous infusion of toxic substancesblood testCT scanningelectrocardiogramnasogastric tube insertion

Contributing factors

  • administration of toxic unproven treatment with no scientific basis
  • inadequate clinical supervision and monitoring of patients receiving IV therapy
  • failure to recognize and respond to clinical deterioration and adverse effects
  • patient and family misinformation about treatment efficacy, risks, and safety
  • philosophy of treatment that discouraged questioning and prevented conventional medical intervention
  • lack of proper medical review and assessment of baseline health status
  • failure to escalate severely ill patients to hospital care
  • substandard clinical conditions including inadequate sterile protocols for IV administration
  • withdrawal or restriction of conventional supportive medications
  • language and practices that blamed patients and families for treatment failure rather than recognizing toxicity
  • absence of informed consent regarding risks of treatment itself

Coroner's recommendations

  1. Restrict or control procurement of caesium chloride and other caesium salts in the same way as Laetrile (B17), requiring restricted access through Commonwealth TGA and state-level Poison Scheduling committees
  2. Therapeutic Goods Administration and state Poison Scheduling committees comprehensively review the list of substances used in this therapy to determine whether restricted access should apply
  3. Department of Immigration & Citizenship closely scrutinise any visa application for entry into Australia by Dr. Helfried Sartori
  4. Data from KPMHC Perth operation be comprehensively evaluated by relevant experts to provide education to medical and health practitioners regarding effects of administration of these substances
  5. Refer Simone Phasey, Merrilee Baker, and Alexandra Boyd to their relevant registering authorities (AHPRA) for determination of appropriateness of their conduct in participating in the treatment
  6. Refer matter to Director of Public Prosecutions for determination whether offences were committed and whether public interest warrants prosecution of those contributing to the four deaths
Full text
Official source Archived copy

Related cases from WA

WA2026-04-28

Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…

psychiatrygeneral practicediagnosticcommunication
WAhospital2026-03-27

Inquest into the Death of Sandipan DHAR

1y · Male·Complications of acute lymphoblastic leukaemia

A 21-month-old boy died from sepsis secondary to pneumonia complicated by undiagnosed acute lymphoblastic leukaemia (ALL). He presented to ED on 22 March with a three-week history of intermittent fever, had seen three GP…

emergency medicinepaediatricsdiagnosticcommunicationparacetamol
WA2026-03-26

Inquest into the Death of Brian John KEALY

42y · Male·Ligature compression of the neck (hanging)

Brian Kealy, aged 42, died by hanging at Hakea Prison on 2 August 2024 while on remand. He had a complex psychiatric history including polysubstance use, personality disorders, and treatment-resistant psychotic symptoms.…

psychiatrygeneral practicediagnosticcommunicationolanzapine

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. Some material may have been redacted or restricted by court order or privacy requirements. 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 — report an inaccuracy here.