Coroner's Court of Western Australia

Inquest into the Death of Matthew John PICKIN

Inquest into the Death of Matthew John PICKIN

Delivered on :28 August 2024

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 7 April 2022 Matthew John Pickin (Mr Pickin) died at Fiona Stanley Hospital from complications, including sepsis, of a left leg infection in association with metastatic lung cancer.  He was 56 years old.

At the time of his death Mr Pickin was serving his sentence of imprisonment at Casuarina Prison, having recently been transferred there from Bunbury Regional Prison for placement in the infirmary, due to his deteriorating health.  By reason of his imprisonment, under the Coroners Act 1996, he was a “person held in care”, an inquest was mandated into his death and the coroner was required to comment on his supervision, treatment and care.  The focus of the inquest was on the quality of his treatment within the context of his lung cancer.

The first sign of Mr Pickin having a potential lung cancer was when he reported coughing up blood during a nursing appointment on 1 October 2021.  The State Coroner was satisfied that medical investigations and follow up following this initial sign were carried out in a timely manner.  Once the CT scan confirmed a likely lung cancer, immediate steps were taken for a respiratory specialist review.  A further CT scan identified brain metastases, and arrangements were made to commence whole brain radiotherapy, followed by chemotherapy and immunotherapy.

Mr Pickin developed a serious bacterial infection in his leg, and he underwent various surgeries and antibiotic treatment at Fiona Stanley Hospital.  His lung cancer progressed, but due to his underlying infection, it was not safe to administer further chemotherapy, given its detrimental effects on his immune system.  His condition deteriorated and it was considered he would not survive further surgery.  The decision was made for comfort care measures with terminal palliative care.

The State Coroner was satisfied that from the time that Mr Pickin showed a sign that raised a suspicion for lung cancer, his treatment and care at Casuarina Prison was appropriately and assiduously managed by the clinical staff in the prison infirmary, in consultation with external medical specialists.  Despite treatment efforts that were commensurate with what may be expected in the community, he continued to deteriorate and died. 

The State Coroner made comments regarding the application of restraints during Mr Pickin’s last admission to Fiona Stanley Hospital, and was satisfied that the Department of Justice has taken steps to provide further guidance to prison staff on the usage of restraints for terminally ill prisoners who are being conveyed to hospital, and during their stay in hospital, to better support transportation in a humane manner, whilst taking account of safety considerations.

Catch Words : Sentenced Prisoner : Supervision, Treatment and Care; Medical Care; Usage of Restraints; Palliative Care; Natural Causes


Last updated: 19-Sep-2024

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