Coroner's Court of Western Australia

Inquest into the Death of Seth Gregory Victor YEEDA

Inquest into the Death of Seth Gregory Victor YEEDA

Delivered on : 20 July 2022

Delivered at : Perth

Finding of : State coroner Fogliani

Recommendations : Yes

Recommendation No. 1

That the Department of Justice and the WA Country Health Service consider working together, and with such other entities as they may consider appropriate, to facilitate the provision of information concerning the status of external referrals and outcomes of external appointments to the Department of Justice (Health Services), and that issues of confidentiality be addressed, to progress the Referral Tracking System.

Recommendation No. 2

That the Department of Justice considers allocating sufficient resources to enable a project team to be established to finalise work currently being undertaken by Dr Rowland to progress the Referral Tracking System.

Recommendation No. 3

That the Department of Justice considers the feasibility of making a list available to custodial officers that outlines any Alerts as to the unfitness for sport or work, that confidentiality issues be addressed, and that guidance be given to the officers on the purpose and expected response to such an Alert (for example, guidance as to when an officer ought to act in a particular way).

Orders/Rules : N/A

Suppression Order : N/A

Summary : Seth Gregory Victor Yeeda (Mr Yeeda) was a 19 year old Aboriginal male who died at the West Kimberley Regional Prison on 3 May 2018 while serving a 14 month custodial term of imprisonment.

As a young child, Mr Yeeda was diagnosed with rheumatic fever.  This illness led to him suffering persisting heart damage, known as rheumatic heart disease.  It was a serious cardiac disease that required regular medication and monitoring over Mr Yeeda’s lifetime.  When he was ten years old, Mr Yeeda underwent surgery for an aortic valve repair.  This surgery was successful, but it was not a cure for his rheumatic heart disease, and he was required to have ongoing monitoring and treatment.

To prevent ongoing damage to the heart valves through recurrent bouts of rheumatic fever, throughout his life, Mr Yeeda was supposed to have regular monthly intramuscular benzathine penicillin G injections.  These were offered to him as required, but on occasion he was resistant and refused to have them, despite the best endeavours used to explain their importance to him and/or his carer.  While the penicillin injections did not reverse the effects of his rheumatic heart disease, they were an important aspect of treatment as they helped prevent further episodes of rheumatic fever.

On 5 May 2017, Mr Yeeda was taken into custody, and he died in custody approximately one year later.  At the time of his death, he had severe aortic valve regurgitation and left ventricular dilatation, as a result of the progression of his rheumatic heart disease.  Mr Yeeda was due to see a cariologist, but the referral from the Prison Medical Officer was not progressed to the stage of having an appointment made for him.  If Mr Yeeda had been seen by the Visiting  Cardiologist it is likely that he would have been advised that he needed urgent surgery for an aortic valve replacement.  Arrangements for such surgery had previously been made for Mr Yeeda in March 2015 and March 2016, but those surgeries were cancelled due to there being no consent for them by or on behalf of Mr Yeeda.  However, the fact that there had been no past consent did not mean there would be no future consent.  It is known that on 5 December 2017, Mr Yeeda agreed for the Prison Medical Officer to refer him to the Visiting  Cardiologist.  This referral was made but for reasons outlined in the finding, related to the transition of the Visiting Cardiology Service, the appointment was not made and Mr Yeeda died approximately five months later.  If Mr Yeeda had undergone aortic valve replacement surgery, it is likely that his death would have been prevented.

The State Coroner was satisfied that the WA Country Health Service bore the ultimate responsibility for the referral not being actioned, that the Department of Justice missed an opportunity in this regard by not having in place a computer-based tracking system with an adequate recall system for managing prisoners who had urgent referrals, and that WA Cardiology missed a number of opportunities to assist in the adequate transition of the Visiting Cardiology service.

The State Coroner was satisfied Mr Yeeda received a high level of treatment and care in respect to his administration of penicillin injections whilst in custody.  However the State Coroner noted the standard was not of sufficient quality in the treatment and care with respect to Mr Yeeda’s rheumatic heart disease and the need for him to be urgently reviewed by the Visiting Cardiologist..

The State Coroner made three recommendations in support for the progression of the Referral Tracking System which is aimed at avoiding prisoners falling through the gaps and missing out on vital medical care and treatment.

Catch Words : Death in Custody : Visiting Cardiology Service : Medical Referrals : Referral Tracking System : Improvements : Aboriginal Youth Wellbeing : Natural Causes

Last updated: 6-Oct-2023

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