Coronial Inquest into the death of Arthur James BONNEY
Delivered on: 22 July 2019
Delivered at: Perth
Finding of: Coroner King
Suppression Order: N/A
Summary: At the time of his death the deceased was a sentenced prisoner in the minimum security section at Casuarina Prison. His medical history included diabetes, severe cardiac disease and chronic renal failure. He was on a stage 3 Department of Corrective Serviceâ€™s terminally ill register.
On 20 June 2013 the deceased was sentenced and initially placed in Hakea Prison for about two weeks and then transferred to Casuarina Prison, where he remained until his death.
Two days after the deceased arrived at Hakea Prison, he experienced sudden cardiac arrest. He was taken to Royal Perth Hospital where he stayed for eight days. He was returned to Hake Prison and was then transferred to Casuarina Prison, where he resided primarily in the infirmary under a standard privileged regime and was employed as an infirmary worker. Over the next two years the deceased was taken to Royal Perth Hospital and Fiona Stanley Hospital approximately 40 times, and for five of those times he was admitted as an emergency patient for heart-related episodes.
On 30 July 2015 the deceased attended Fiona Stanley Hospital and underwent an upper abdomen CT with contrast. Following the CT scan, the deceased was transferred back to Casuarina Prison. Neither his serum creatinine nor his eGFR level was checked within 48 hours of the CT scan.
On the morning of 3 August 2015 the deceased presented to the diabetic parade at Casuarina Prison. He complained of generalised body aches for two days and abdominal pain, nausea, loose stools and reduced appetite. He was not in acute distress and his vital signs were normal. He showed no shortness of breath, chest pain or signs of acute heart failure. He was diagnosed as suffering acute viral gastroenteritis and prescribed paracetamol and metoclopramide. Later that day the deceased informed the prison nurse he was still not feeling well and after being seen by the prison doctor he was transferred to the emergency department at Fiona Stanley Hospital for further assessment.
At Fiona Stanley Hospital the deceased presented as hyperkalaemic and acidotic. He was transferred from the emergency department to the ICU in the early hours of 4 August 2015 and was diagnosed with acute-on-chronic renal failure requiring dialysis, possibly precipitated by recent contrast CT and compounded by continuing to take nephrotoxic medications. Cardiogenic shock/low cardiac state was also diagnosed and an underlying septic source was queried.
Despite treatment in the ICU, the deceasedâ€™s condition deteriorated until he died on 5 August 2015.
Catch Words: Death in Custody : Natural Causes.
Report: Arthur James BONNEY