Coroner's Court of Western Australia

Inquest into the Death of Frank ALBERT

Inquest into the Death of Frank ALBERT

Delivered on :13 March 2023

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation No. 1

I recommend that the Department of Justice issue a state-wide bulletin reminding staff that whenever they contact emergency services (i.e.: 000) to request an ambulance, they should be able to state the relevant prisoner’s name, age (and where relevant) ethnicity, as well as the nature of the emergency, and whether the prisoner is awake and/or breathing.

Recommendation No. 2

I recommend that the Department of Justice conduct a review of the “All calls to 000” table in the West Kimberley Regional Prison Local Emergency Plan to ensure that it lists the key information staff contacting emergency services (i.e.: 000) should provide the emergency services operator, including the relevant prisoner’s name, age (and where relevant) ethnicity, as well as the nature of the emergency, and whether the prisoner is awake and/or breathing.

Recommendation No. 3

I recommend that the Department of Justice conduct a review of the time and staff resources allocated to medication parades in order to determine whether those resources are sufficient to prevent the illicit trafficking of prescription medication within the prison estate.  The review should also consider whether there are any additional measures that could be implemented to assist in detecting medication secretion/diversion attempts by prisoners, particularly in relation to those medications which are more trafficable, such as quetiapine.

Recommendation No. 4

I recommend that the Department of Justice redouble its efforts to recruit Aboriginal health workers (AHW), especially for regional prisons, with a view to examining the feasibility of ensuring that all Aboriginal prisoners with chronic medical conditions are reviewed by an AHW on their initial admission, and thereafter as appropriate.  The purpose of such reviews would include (but not be limited to) identifying any treatment gaps in the prisoner’s care and providing culturally appropriate education about the potential benefits of recommended prescription medication and/or investigative procedures.

Recommendation No. 5

I recommend that the Department of Justice liaise with appropriate Aboriginal organisations and Aboriginal health workers with a view to developing culturally appropriate dietary options for Aboriginal prisoners with diabetes, and that these dietary options be proactively offered to those prisoners.

Orders/Rules : Yes

Suppression Order : N/A

On the basis that it would be contrary to the public interest, I make an Order under section 49(1)(b) of the Coroners Act 1996 that there be no reporting or publication of the name of any prisoner (other than the deceased) housed at West Kimberley Regional Prison.  Any such prisoner is to be referred to as “Prisoner [Initial]”.  Order made by: MAG Jenkin, Coroner (21.02.23)

Summary : Mr Frank Albert (Mr Albert) was 46-years of age when he died at Derby Regional Hospital (DRH) from atherosclerotic heart disease on 8 January 2021.  At the time of his death, Mr Albert was a sentenced prisoner at West Kimberley Regional Prison (WKRP), having been initially received at the Broome Regional Prison on 17 October 2019.  During a risk assessment conducted during the reception process, Mr Albert mentioned he was on medication for diabetes but otherwise had no serious medical issues.

During his incarceration at WKRP, Mr Albert was regularly seen by nursing staff who encouraged him to take his diabetes medication.  However, Mr Albert was adamant he did not wish to do so, saying the medication gave him chest pains.  He also refused to undergo a cardiac stress test to check his heart function.  Mr Albert said he preferred to manage his diabetes by exercise and diet and was given information about healthy eating.  Eventually, after being seen by a physician on 25 September 2020, Mr Albert agreed to start taking his diabetes medication, but his blood sugar levels remained high and he was prescribed additional medication.

One of the issues explored at the inquest was whether Mr Albert’s health outcomes may have been improved if he had been seen by and Aboriginal health worker (AHW), who could have explained the need for medication and the stress test in culturally appropriate ways.  Despite the obvious potential benefits of a review by an AHW, this was not possible because none are employed at WKRP.

Another issue that was explored at the inquest was the availability of culturally appropriate diet options for Aboriginal prisoners with diabetes.  The coroner noted that although culturally appropriate foods are made available to prisoners at WKRP, none of the Department of Justice’s polices relating to food appears to specifically deal with appropriate diet options for Aboriginal prisoners with diabetes.

Just after 9.00 am on 8 January 2021, prison officers were alerted to the fact that Mr Albert was in his cell clutching his chest, apparently having a heart attack.  Nurses attended and Mr Albert was given aspirin and glyceryl trinitrate spray, before being taken to DRH by ambulance.  As Mr Albert was being prepared for transfer to Perth for further management, his condition suddenly deteriorated.  At about 12.00 pm he went into cardiac arrest, and despite resuscitation efforts, he could not be revived.

Whilst he was at DRH, Mr Albert told clinical staff he had “smoked a pill” the night before.  This turned out to be a portion of a quetiapine tablet, which Mr Albert was not prescribed.  He had obtained the quetiapine from another prisoner who had secreted the medication after being given it by a nurse.  Evidence from several prisoners at WKRP suggests that the practice of secreting medication is widespread.

Although Mr Albert had significant heart disease and quetiapine can place a person at risk of developing a fatal arrythmia, there was no evidence that Mr Albert’s death was due to quetiapine toxicity.  Instead, his cardiac arrest appeared to be related to insufficient blood flow to his heart cause by his pre-existing heart disease.

The Coroner concluded that although Mr Albert’s supervision, treatment and care was of an appropriate standard, the fact that he was able to access a potentially dangerous medication that was not prescribed to him, was a serious breach of security at WKRP.  The coroner made five recommendations aimed at improving the health and safety of prisoners at WKRP.

Catch Words : Death in Custody : Aboriginal health workers : Culturally appropriate diets : Diabetes management : Chronic Medical Conditions : Trafficking of prescription medications : Natural Causes

Last updated: 27-Mar-2023

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