Coroner's Court of Western Australia

Inquest into the Death of Augustinus Clemens Antonius HEESTERS

Inquest into the Death of Augustinus Clemens Antonius HEESTERS

Delivered on: 12 October 2018

Delivered at: Perth

Finding of: Deputy State Coroner Vicker

Recommendations: N/A

Orders/Rules: N/A

Suppression Order: N/A

Summary: The deceased at the time of his death was a sentenced prisoner located at Fiona Stanley Hospital following a procedure to insert a stent into his right coronary artery on 14 October 2016. Initially the deceased appeared to be recovering well, but then developed ventricular tachycardia and arrested. He was revived, but remained unstable before declining further intervention. The deceased was 70 years of age.

The deceased had a long history of ischaemic heart disease with two prior myocardial infarctions. His medical history recorded lumbar back pain, cuff tear repair surgery to the right shoulder, skin cancer, bipolar affective disorder, hyperlipidemia, gastro-oesophageal respiratory disease, right inguinal hernia and depression. He was prescribed multiple medications for his various ailments. Indications were the deceased was not always compliant with his medication.

The deceased was sentenced on 1 March 2016 to a term of imprisonment of 1 year and 6 months. On 7 April 2016 he was transferred to the Bunbury Regional Prison at his request where he remained a sentenced prisoner until 6 October 2016.

On 5 October 2016 a nurse was called to the deceased’s unit at to assess the deceased. The nurse immediately called an ambulance. The deceased was transferred to Bunbury Regional Hospital. The deceased was assessed, stabilised and transferred to Fiona Stanley Hospital via the Royal Flying Doctor Service for further management. At Fiona Stanley Hospital the deceased was admitted to the coronary care unit.

On the morning of 10 October 2016 the deceased’s oxygen saturations were noted to be dropping and his blood pressure remained low. He showed signs of pulmonary oedema and his diuretic was increased. On 12 October 2016 his MRI showed his heart showed severe systolic dysfunction. A repeat angiogram on 14 October 2016 inserted a stent into the RCA and the deceased appeared to recover after the procedure. Later that evening he developed VT and arrested. As a result of the deceased required increasing amounts of support, but declined further resuscitation. The deceased had a telephone discussion with his partner as he deteriorated and he passed away in the morning of 15 October 2016.

The Coroner concluded the deceased’s supervision, treatment and care while in custody to have been of a good standard.

Catch Words: Death in Custody : Care Plans : Natural Causes.


Last updated: 30-Apr-2019

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