Inquest into the Death of David John HATCHER
Delivered on: 1 April 2026
Delivered at: Perth
Finding of: Robyn Hartley
Recommendations: No
Orders/Rules: No
Suppression Order: N/A
Summary:
David John Hatcher (Mr Hatcher) was 60 years old and died at Fiona Stanley Hospital (FSH) on 27 September 2024 from pulmonary tuberculosis with a background of chronic obstructive pulmonary disease.
The Coroner observed that Mr Hatcher had multiple serious pre-existing medical conditions which affected his respiratory system when he was admitted to Hakea Prison on 8 August 2023. In January 2024 Mr Hatcher was reviewed at the General Respiratory Clinic at FSH for treatment of his severe chronic obstructive pulmonary disease (COPD). Mr Hatcher experienced a medical episode on 7 May 2024 and was transferred to FSH where he was diagnosed with active pulmonary tuberculosis. During the hospital admission Mr Hatcher was registered as Stage 3 Terminally Ill. He returned to prison 6 June 2024 but became very unwell soon after and was again transferred to FSH. Throughout Mr Hatcher’s final admission to hospital, he was escalated and deescalated between Stage 3 and Stage 4 Terminally Ill due to his unstable condition. Mr Hatcher was provided comprehensive care by three specialist teams at FSH but they were unable to halt his deterioration which was exacerbated by his reluctance to engage with health professionals to improve his physical and mental health.
The Coroner found the supervision, treatment and care provided to Mr Hatcher by the Department of Justice (the Department) was of an acceptable standard. However, the Coroner accepted the findings made by the Department in their internal review that Mr Hatcher was restrained in breach of policy on two occasions in the months before his death when he was registered as Stage 3 Terminally Ill. The Coroner highlighted the importance of accurate recording in the prison systems when a prisoner is registered as terminally ill.
Catch Words: Death in Custody, Natural Causes; Restraints
Last updated: 28 April 2026