Inquest into the Death of Lewis Walter WARD

Male·out-of-hospital cardiac arrest due to atherosclerotic cardiovascular disease and Type 2 diabetes mellitus

Lewis Walter Ward, a Ngarinyin man in his early thirties, died from out-of-hospital cardiac arrest while playing sport at West Kimberley Regional Prison. He had Type 2 diabetes, hypertension, dyslipidaemia, and was a smoker. In October 2021, prison doctors identified evidence of previous myocardial infarction on ECG and referred him for an exercise stress test. The appointment scheduled for February 2022 was missed, then erroneously marked as attended in hospital records, preventing prompt rescheduling. The error went undetected for 630 days until a new appointment was booked for 18 July 2023—two days after his collapse. Expert evidence suggested earlier testing may not have changed the outcome, as he was asymptomatic and already on appropriate cardiovascular medications. The coroner found this a 'missed opportunity' but not conclusively preventable. The Department subsequently implemented improved referral tracking systems.