Inquest into the Death of Lewis Walter WARD
Inquest into the Death of Lewis Walter WARD
Delivered on : 8 January 2026
Delivered at : Perth
Finding of : Acting State Coroner Sarah Linton
Recommendations : I recommend that the Department of Justice consider improving the coverage of CCTV cameras over the football oval at West Kimberley Regional Prison. Further, I recommend the Department of Justice continue to work towards introducing body worn cameras in all prisons, including at West Kimberley Regional Prison.
Orders/Rules : N/A
Suppression Order : N/A
Summary : Lewis Walter Ward (Mr Ward) died on 25 July 2023 at Royal Perth Hospital. At the time of his death Mr Ward was a sentenced prisoner at the West Kimberley Regional Prison Derby therefore an inquest into his death was mandatory.
Mr Ward was a Ngarinyin, Woddorda and Wunumbal man who grew up in communities across the West Kimberley region. In August 2021 Mr Ward was sentenced to imprisonment for a serious act of violence involving his baby daughter. She had been the unintended victim of an act of violence directed towards his partner. Mr Ward was eligible to be considered for release on parole in September 2023.
Mr Ward was in his early thirties had a number of diagnosed health conditions when he was admitted to prison for the last time, including Type 2 Diabetes and high cholesterol. He had been receiving treatment for his diabetes and other health conditions for many years, including being prescribed medications, but he generally only complied with his treatment regime when in custody. He was restarted on his medications and put on a diabetes management plan on his return to prison, and he was generally compliant with his treatment and engaged with the prison health staff.
Mr Ward underwent an ECG in prison, which had an abnormal result. As a result, a referral to a cardiologist for an exercise stress test was made in October 2021, with the appointment booked for February 2022. Unfortunately, due to some miscommunication, Mr Ward was not sent to the external hospital appointment and the missed appointment was not identified for a considerable length of time. On 3 July 2023, the missed appointment was finally identified, at which time another appointment was made for 18 July 2023. However, Mr Ward collapsed three days before the appointment.
On 15 July 2023 Mr Ward was playing football on an oval at the West Kimberley Regional Prison when he collapsed. He was taken by ambulance to Derby Hospital for medical treatment and subsequently transferred by Royal Flying Doctor Service to Perth. He was admitted to the Intensive Care Unit at Royal Perth Hospital. A CT head scan conducted on 24 July 2023 confirmed a hypoxic brain injury and brain death.
Following a post mortem examination, a forensic pathologist formed the opinion that the collapse and cardiac arrest occurred most likely due to atherosclerotic heart disease, which was severe.
Since Mr Ward’s unexpected death the Department has taken steps to improve its internal systems for managing external referrals to ensure referrals are tracked and followed up.
The Acting State Coroner found Mr Ward died as a result of natural causes. The Acting State Coroner made one recommendation in relation to CCTV cameras at West Kimberley Regional Prison and the rollout of body worn cameras in all prisons.
Catch Words : Mandatory Inquest : Death in Care : Cardiac Death : Specialist Referrals : Natural Causes
Last updated: 21 January 2026