Coroner's Court of Western Australia

Inquest into the Death of Paul Stephen KEATING

Inquest into the Death of Paul Stephen KEATING

Delivered on : 6 July 2022

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Keating died on 12 May 2020 at Fiona Stanley Hospital from atherosclerotic heart disease. At the time of his death, Mr Keating was a sentenced prisoner. He was 60 years old.

On 11 May 2020, Mr Keating was in his cell when he used the cell call system to advise prison staff he was having difficulty breathing, and had chest pain.  Two male prison officers went to Mr Keating’s cell, where Mr Keating stated he could not breathe, and one of the prison officers retrieved an oxy-viva resuscitator and a defibrillator, while the other prison officer called a Code Red medical emergency. Two on-duty prison nursing staff responded to the Code Red medical emergency, but due to an active alert restricting female prison staff from having contact with Mr Keating, they did not enter his cell. Instead they remained in the unit’s control room and provided advice to the prison officers who were attending to Mr Keating. After several minutes, Mr Keating stopped using the oxygen mask, saying he could breathe better without it. Despite the aid he was receiving, Mr Keating’s condition deteriorated, and he became sweaty before losing consciousness. The call for an ambulance had earlier been made and the ambulance arrived at the entrance to Casuarina Prison.

Paramedics attended and noted CPR was being conducted by prison officers. They then assumed control of Mr Keating’s care and CPR was continued before he was taken by ambulance to Fiona Stanley Hospital. Upon attending the emergency department at Fiona Stanley Hospital at 12.34 am on 12 May 2020, Mr Keating could not be revived, and he was pronounced deceased at 12.45 am.

The Coroner was satisfied that Mr Keating’s various medical conditions, including his chronic heart disease, were appropriately managed and the standard of supervision, treatment and care he received whilst he was in custody was appropriate.

Catch Words : Death in Custody : Supervision, Treatment and Care : Natural Causes

Last updated: 9-Aug-2022

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