Coroner's Court of Western Australia

Inquest into the Death of Joseph Thomas ROE

Inquest into the Death of Joseph Thomas ROE

Delivered on : 1 November 2021

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Roe died on 21 September 2017 at Sir Charles Gardiner Hospital. At the time of his death Mr Roe was a sentenced prisoner.  He was 50 years of age.

Just after midnight on 18 September 2017, Mr Roe’s cell mate heard Mr Roe making strange sounds and saw him shaking and then vomiting. Mr Roe’s cell mate pressed the cell’s emergency button.  Prison officers responded to the cell call and contacted medical staff to meet at Mr Roe’s cell.

A prison nurse attended the cell and assessed Mr Roe who, by this stage, was unconscious. He was taken to the prison’s infirmary where the call was made for an ambulance to attend. The ambulance took Mr Roe to Fiona Stanley Hospital, where he was seen immediately and was intubated and ventilated.  Scans suggested a ruptured brain aneurysm.  Mr Roe was then transferred to the specialist neurosurgical unit at Sir Charles Gardiner Hospital. There was no improvement in his condition when sedation was withdrawn, and further intervention was deemed futile.

The Coroner was generally satisfied that Mr Roe received proper supervision, treatment and care of Mr Roe by prison staff at Casuarina. The only significant oversight was the failure to call a Code Red medical emergency by prison staff when it was ascertained that Mr Roe was unconscious and having seizures, however the Coroner was satisfied this failure did not contribute to his death. The Coroner found there was no immediate warning that Mr Roe was about to sustain a ruptured berry aneurysm, which occurred sometime in the evening of 17 September 2017.

Catch Words : Death in Custody: Quality of Supervision, treatment and care: Natural Causes

Last updated: 15-Nov-2021

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