Coroner's Court of Western Australia

Inquest into the Death of James Alexander TILBURY

Inquest into the Death of James Alexander TILBURY

Delivered on :21 December 2021

Delivered at : Perth

Finding of : Deputy state Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : At the time of his death Mr tilbury was a sentenced prisoner.  He died on 4 July 2019 at Bethesda Hospital due to complications of a brain tumour.  He was 77 years old.

Mr Tilbury was serving a life sentence.  He had spent the majority of his life in custody from 1971 onwards until his death.  In 1996 he was diagnosed with asthma/COPD following many years of smoking.  He did try to give up smoking on several occasions, but was unsuccessful.  In June 2005 he was diagnosed with prostate cancer and underwent radiotherapy.  In July 2010.   Mr Tilbury suffered facial burns after lighting a cigarette near his oxygen apparatus which caused a small explosion.  Nevertheless, he continued to smoke.  On 4 January 2013 Mr Tilbury was assaulted by another prisoner and required hospitalisation due to internal bleeding and a suspected ruptured spleen.

On 2 May 2014, Mr Tilbury was listed as Phase 1 terminally ill on the Department’s Terminally Ill Register after he was diagnosed with COPD in addition to his prostate cancer.  In September 2014 he was permanently housed in the infirmary at Casuarina Prison due to his ongoing health issues.  In addition to his COPD and prostrate cancer.  He was also experiencing recurrent pneumonia and urinary tract infections and had been diagnosed with ischaemic heart disease, diabetes and depression.  Mr Tilbury’s health continued to deteriorate.  There where times when he was put on the At Risk Management System because he refused to eat, drink or take his medication, and he received ongoing prison counselling services and health interventions.

Mr Tilbury was commenced on morphine in late 2017 for his worsening breathlessness.  By late 2017 early 2018, there were indications he could no longer care for himself, and in 2018, a number of additional illnesses were added to his medical conditions.  He was reviewed by a palliative care team in June 2018.  On 31 May 2019, Mr Tilbury was transferred by ambulance to Fiona Stanley Hospital for medical treatment after he failed to attend the medication round and was found in bed, confused and complaining of a headache.  He was diagnosed with a large brain tumour, and moved to Sir Charles Gairdner Hospital on the same day.  Mr Tilbury indicated to his treating doctors that he was not interested in pursuing further investigations or having oncology treatment.

On 24 June 2019, Mr Tilbury was transferred to Bethesda Hospice for palliative care.  On 4 July 2019 was Mr Tilbury was declared deceased.

The Deputy State Coroner was satisfied Mr Tilbury received a high standard of care, which was generally better than he would have received if he had been in the community when he became terminally ill.

Catch Words : Death in Custody : treatment, Supervision and Care : Management of Terminally Ill Prisoners : Natural Causes

Last updated: 19-Mar-2022

[ back to top ]