Coroner's Court of Western Australia

Inquest into the Death of Michael James HARDIE

Inquest into the Death of Michael James HARDIE

Delivered on : 5 August 2022

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

As a matter of urgency, the Department of Justice (DOJ) should create a "Management Transfer" alert within the Alerts Module of the Total Offender Management System (TOMS) which will be activated whenever a prisoner is being transferred between prisons due to matters relating to security and/or safety, including in circumstances where the prisoner is suspected of being involved in the movement of illicit substances whether by drug trafficking or otherwise.

 Recommendation No. 2

Whenever a prisoner is being transferred from one custodial facility to another because of concerns they are or may be involved in the movement of illicit substances, whether by drug trafficking or otherwise, DOJ should require the security manager (or equivalent) of the transferring facility to contact the security manager (or equivalent) of the receiving facility to alert them to the reason for the prisoner’s transfer and to discuss suggested surveillance measures.  Wherever possible this contact should occur verbally and be appropriately documented by means of a follow up email.

Recommendation No. 3

As soon as practicable, DOJ should develop and finalise policies and procedures dealing with end-of-life planning for prisoners, including:

 (a) the discussion and documentation of prisoners' goals of care, including advanced health directives; and

(b) processes and procedures dealing with:

      (i) the ability of prisoners to make "Do Not Resuscitate" (DNR) decisions; and

      (ii) the response of prison staff' to medical emergencies in circumstances where a prisoner has made a DNR decision.

 As part of this process, DOJ should give consideration to the appropriateness of creating of a DNR alert within TOMS.

Orders/Rules : No

Suppression Order : Yes

On the basis that it would be contrary to the public interest, I make an order under section 49(1)(b) of the Coroners Act 1996 (WA) that there be no reporting or publication of any document or evidence that would reveal any information about the methods of detecting illicit drugs, including methylamphetamine, with respect to persons under the care and control of the Director-General of the Department of Justice.

Summary : Mr Michael James Hardie (Mr Hardie) died on 7 February 2020 at Fiona Stanley Hospital (FSH) from ruptured thoracic aortic aneurysm in a man with Marfan syndrome and methylamphetamine effect.  At the time of his death, Mr Hardie was a sentenced prisoner at Casuarina Prison.  He was 41-years of age.

Mr Hardie was born with Marfan syndrome, a genetic disorder affecting the body’s connective tissues that can cause issues with the heart, eyes, blood vessels, and skeleton.  Those with Marfan syndrome typically have unusually elongated limbs, fingers, and toes.  Mr Hardie’s most significant medical issue was a thoracoabdominal aortic aneurysm (an enlarged area of the lower part of his aorta).  Although Mr Hardie underwent various surgical procedures, because of the size of his aneurysm, there were limited treatment options as there were no stents big enough for a closed repair, and an open repair carried a high risk of paralysis and death.  Mr Hardie’s condition was managed conservatively, meaning he was prescribed medication designed to ensure his blood pressure remained as low as possible.  Nevertheless, there remained a very high risk that Mr Hardie’s aneurysm would eventually rupture and that when it did, his chances of survival would be minimal.

Mr Hardie had an extensive criminal record, and by 2020, he had accumulated 51 convictions for various offences including stealing, burglarly, armed robbery and drug-related offences.  On 11 May 2018, in the District Court of Western Australia at Perth, Mr Hardie was sentenced to a term of 5 years and nine months’ imprisonment (without eligibility for parole), in relation to one count of posessing stolen property and two counts of possessing methylamphetamine with intent to sell or supply.

On 11 October 2019, Mr Hardie was transferred from Acacia Prison (Acacia) to Casuarina Prison (Casuarina) because it was suspected he was involved in the movement of illicit substances (i.e.: drug trafficking) within the prison.  The intent was to disrupt drug networks at Acacia by moving Mr Hardie to Casuarina.  Notwithstanding the sound basis for moving Mr Hardie out of Acacia, in a major communication breakdown, security staff at Casuarina were not made aware of the intelligence underpinning his transfer.  As a result, Mr Hardie was not subjected to for targeted searches and random drug tests on his arrival at Casuarina.

Prior to the morning unlock at Casuarina on 7 February 2020, Mr Hardie was chatting to his cell mate as he cleaned their cell.  Shortly before 8.10 am, Mr Hardie suddenly reached his hand towards his cell mate before collapsing to the floor.  Custodial staff were alerted and CPR was immediately commenced, but Mr Hardie could not be revived.

A forensic pathologist conducted an external post mortem examination, before expressing the opinion that the cause of Mr Hardie’s death was haemothorax (i.e.: collections of blood in the pleural cavity) due to ruptured thoracic aortic aneurysm in a man with Marfan syndrome and methylamphetamine effect.  Toxicological analysis detected a significant level of methylamphetamine in Mr Hardie’s system, which a toxicologist considered had caused Mr Hardie’s aneurysm to rupture.

The Coroner concluded that the treatment and care provided to Mr Hardie whilst he was in prison was appropriate and commensurate with community standards.  However, the coroner found the fact that Mr Hardie was able to obtain methylamphetamine whilst he was in custody, in circumstances where he was not subject to random or targeted cell searches or drug tests, meant that the supervision Mr Hardie received whilst incarcerated was clearly and demonstrably substandard.

The coroner made a total of three recommendations.  Two were aimed at improving security arrangements within prisons and the third urged DOJ to develop polices relating to end-of-life planning for prisoners.

Catch Words : Death in Custody : Management Transfers : Chronic Medical Conditions : End-of-life planning : Illicit substances in prisons : Accident

Last updated: 18-Aug-2022

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