Inquest into the Death of Alan David RATCLIFF

Inquest into the Death of Alan David RATCLIFF

Delivered on : 10 April 2024

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Alan David Ratcliff (Mr Ratcliff) died on 20 January 2022 at Sir Charles Gairdner Hospital (SCGH), from complications of intracranial haemorrhage.  He was 65-years of age. 

Mr Ratcliff had an extensive criminal history, and at the time of his death, he was a sentenced prisoner at Acacia Prison (Acacia)

Mr Ratcliff’s medical history included high blood pressure, high cholesterol, asthma, and migraines with sensory disturbances (aura).  On Mr Ratcliff had a CT scan at Fiona Stanley Hospital (FSH) to investigate recurrent issues with migraine headaches and double vision.  The scan indicated Mr Ratcliff may have posterior reversible encephalopathy syndrome, which is characterised by headaches and vision issues, and although a prison doctor referred him to a neurologist, prison records indicate that no neurology review appointment was made prior to Mr Ratcliff’s death.

Shortly after 4.25 pm on 12 June 2022, prison officers responded to an emergency call from Mr Ratcliff’s cellmate who said Mr Ratcliff was disorientated.  Prison officers found Mr Ratcliff on the floor of his cell unable to answer basic questions and suspected he was having a stroke.  He was taken the prison medical centre and found to have a left-sided facial droop and left sided weakness left-sided weakness, and he also tested positive for COVID-19.

Mr Ratcliff was taken to SCGH by ambulance, where tests confirmed he had experienced a haemorrhagic stroke.  Mr Ratcliff was assessed as being an unsuitable candidate for surgery, and he was treated palliatively.

At 6.25 am on 20 June 2022the officers supervising Mr Ratcliff noticed that he appeared to have stopped breathing.  Following an assessment, clinical staff declared Mr Ratcliff deceased at 6.57 am.

After carefully considering the available evidence, the coroner was satisfied that the supervision, treatment and care that Mr Ratcliff received whilst he was incarcerated was of an acceptable standard.

The coroner also noted that although clearly unfortunate Mr Ratcliff was not seen by a neurologist, on the basis of the available evidence, it was not possible to make any findings, to the relevant standard, about whether failure to have Mr Ratcliff reviewed by a neurologist had any impact on his death.

Catch Words : Death in custody : Intracranial haemorrhage : Natural causes

Last updated: 30-Apr-2024

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