Inquest into the Death of Hugh WARD

89y · Male·Complications of cerebrovascular accident (stroke); specifically a catastrophic left-sided embolic stroke

Hugh Ward, an 89-year-old sentenced prisoner, died from complications of stroke following an embolic cerebrovascular accident at Sir Charles Gairdner Hospital. While incarcerated, Mr Ward had multiple comorbidities including atrial fibrillation, heart disease, diabetes, and dementia. A critical clinical challenge involved balancing anticoagulation therapy to prevent embolic stroke against his high gastrointestinal bleeding risk following gastric ulcers and his frequent falls. His anticoagulant (apixaban) was withheld from July 2021 onwards due to bleeding risk exceeding stroke risk. Medical care was considered thorough and compassionate. Key systemic issues included: failure to promptly record an Enduring Power of Guardianship in the medical record, leading to cancellation of a medically indicated gastroscopy in September 2020; and inadequate family communication about his medical condition despite valid written consents. Administrative gaps in information management between prison systems (TOMS) and medical records (EcHO) compromised care coordination and family involvement in his deteriorating condition.