Inquest into the Death of Karl Frederick Dominic HOLMES

66y · Male·Complications of metastatic lung adenocarcinoma, with terminal palliative care, in a man with multiple medical comorbidities

Karl Frederick Dominic Holmes, a 66-year-old prisoner with metastatic lung adenocarcinoma and hepatocellular carcinoma, died from complications of his terminal cancer while serving a 7-year sentence. He received excellent medical care from Dr S. who actively managed his investigations, specialist referrals, and supported his informed decision to refuse potentially curative treatment. Holmes rapidly deteriorated in January 2023 and was transferred to Fiona Stanley Hospital where he died. The coroner commended the medical care but identified issues: (1) delayed dental treatment despite identified need and multiple requests, and (2) failure to complete an External Movement Risk Assessment before emergency transfer, resulting in unnecessary restraints applied to a terminally ill, frail patient. The coroner noted dental care deficiencies and recommended the Department improve dental service consistency across prisons, replicating the successful model at Hakea Prison.