Coroner's Court of Western Australia

Inquest into the Death of Roy Charles GILBERT

Inquest into the Death of Roy Charles GILBERT

Delivered on :8 July 2015

Delivered at : Perth

Finding of : Deputy State Coroner Vicker

Recommendations :N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was a sentenced prisoner at the time of his death serving an indefinite term of imprisonment at his Governor’s pleasure.  In August 2013 the deceased was diagnosed with Gastric Adenacarcinoma (stomach cancer), however he was significantly non-compliant with treatment until his condition became severe and he consented to firstly surgery, and later oral chemotherapy.  In November 2013 he was registered as a Phase 1 terminally ill prisoner and Phase 2 in December, shortly before his death in Royal Perth Hospital from his malignancy on 21 December 2013.  The deceased was 49 years of age.

The deceased had a significant juvenile criminal justice record which resulted in frequent time spent in correctional institutions.  He spent well over 30 years in institutions, with 29 of those in prison.  During the initial finite term of the deceased’s imprisonment he was incarcerated in various prison facilities available at that time but was generally considered to be a management problem due to his insulting or threatening behaviour, anger management and use of illicit substances.

The Deputy State Coroner found the deceased was generally physically well but with bouts of depression which related to his offending and incarceration.  The Deputy State Coroner found the deceased first showed signs of gastrointestinal tract issues in 2009 to 2011 but these appeared to respond to treatment.  He was admitted to Royal Perth Hospital on 12 August 2014 due to continuing loose of weight, abdominal discomfort and bloating.  Investigations diagnosed a poorly differentiated adenocarcinoma of the stomach.  The deceased was managed by Royal Perth Hospital’s oncology team with the assistance of medical staff at both the Casuarina Prison Infirmary and the Acacia Prison Infirmary.

In October 2013 tests showed that metastases were present throughout the peritoneal cavity and the deceased’s tumour continued to spread despite aggressive treatment until chemotherapy was withdrawn and palliative therapy commenced.  The deceased was admitted to Royal Perth Hospital for the last time on 16 December 2013 at which time he was declared a terminally ill prisoner, Phase 2, with death imminent.

The Deputy State Coroner concluded that the deceased died on 21 December 2013 at Royal Perth Hospital, as a result of complications in association with advanced gastric malignancy and he died by way of natural causes.

The Deputy State Coroner was satisfied the overall treatment by the Department of Corrective Services in conjunction with the intervention the deceased would allow from Royal Perth Hospital was appropriate, and the quality of his supervision, treatment and care reasonable in view of the aggressiveness of his cancer and periods of noncompliance with management.

Catch Words : Death in Custody, Prison : Long term prisoner : Natural Causes.


Last updated: 12-Mar-2024

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