Inquest into the Death of Alan David RATCLIFF

65y · Male·complications of intracranial haemorrhage (hypertensive haemorrhage), with terminal palliative care

Alan David Ratcliff, a 65-year-old prisoner at Acacia Prison, died from complications of intracranial haemorrhage (hypertensive haemorrhage) on 20 June 2022. He collapsed on 12 June 2022 with stroke symptoms and was hospitalised at Sir Charles Gairdner Hospital, where he was managed palliatively. Key clinical lessons include: (1) an outstanding neurology referral for recurrent migraines with aura was never completed—an MRI may have identified an aneurysm amenable to monitoring or surgical intervention; (2) inappropriate use of restraints was initially applied during hospitalisation of a terminally ill patient, though departmental policy has since been updated; (3) COVID-19 infection two days before collapse may have contributed to vascular susceptibility through inflammation, though this remains speculative. Overall, medical care was of high standard and commensurate with community care, with the primary missed opportunity being completion of neurology review.