Inquest into the Death of Edward Ivan AFRICH

64y · Male·bronchopneumonia and sepsis with chronic obstructive pulmonary disease in a man with underlying advanced chronic myelomonocytic leukaemia and heart failure, medically palliated

Edward Ivan Africh, a 64-year-old sentenced prisoner, died from bronchopneumonia and sepsis with chronic obstructive pulmonary disease (emphysema) in the setting of advanced chronic myelomonocytic leukaemia and heart failure. Key clinical lessons include: (1) communication of medical information between facilities was inadequate—his general practitioner's health summary documenting emphysema was not forwarded from Hakea to Acacia Prison; (2) his emphysema was not identified or managed appropriately during his 9-month imprisonment despite being disclosed verbally; (3) when diagnosed with severe emphysema in December 2018, no specific treatment (bronchodilators, puffers, physiotherapy) was initiated at Casuarina Prison infirmary; (4) he was inappropriately placed in a shared cell with heavy smokers for months, exacerbating his lung disease; (5) he was inappropriately restrained after hospital admission despite being terminally ill on palliative care. The coroner found the general medical care otherwise appropriate for complex comorbidities, but identified significant failures regarding emphysema management and the use of restraints on a dying prisoner.