Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia
Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Inquest into the Death of Graham John BUTLER

Inquest into the Death of Graham John BUTLER

Delivered on : 12 June 2025

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Graham John Butler (Mr Butler) was 76-years of age when she died at St John of God Midland Public Hospital (SJOG) on 22 October 2023, after experiencing an out of hospital cardiac arrest.

At the time of his death, Mr Butler was a sentenced prisoner at Acacia Prison (Acacia), following his conviction in relation to six child sexual offences.  Mr Butler’s medical history included: type 2 diabetes, ischaemic heart disease, angina, high blood pressure, high cholesterol, diverticulitis, gastro-oesophageal reflux disease, chronic low back pain, depression, anxiety, and recurrent urinary tract infections.  Mr Butler had experienced a cerebrovascular accident (“stroke”) in 2003, a myocardial infarction (“heart attack”) in 2013, and a transient ischaemic attack in 2015.

During a routine cell check just before 7.00 pm, on 22 October 2023, Mr Butler was found lying unresponsive on his bed.  CPR was commenced and ambulance officers arrived at Acacia and took Mr Butler to SJOG.  Despite further resuscitation efforts, Mr Butler could not be revived, and he was declared deceased at 8.20 pm on 22 October 2023.

After carefully reviewed the available evidence, the coroner was satisfied that the standard of supervision, treatment, and care Mr Butler received whilst he was incarcerated was of a very good standard.  Further, the coroner concluded that Mr Butler’s medical care was equal to or better than the care he would have received in the community.

Catch Words : Death in Custody : Elderly prisoner : Chronic Medical Conditions : Natural Causes


Last updated: 3 July 2025

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