Coroner's Court of Western Australia

Inquest into the Death of Shane John ROBINSON

Delivered on: 22 June 2015

Delivered at: Perth

Finding of: Coroner Linton

Recommendations: N/A

Orders/Rules: N/A

Suppression Order: N/A

Summary: The deceased was 29 years of age at the time of his death. He was a sentenced prisoner at Casuarina Prison. On 10 June 2011 the deceased was found in an unresponsive state in his cell shortly after an early morning cell check. He could not be revived despite cardiopulmonary resuscitation being attempted.

The inquest focussed primarily on the ongoing health issues of the deceased, his medical treatment while in prison, and how he may have been able to access the drugs that, in combination, caused his death and the steps taken by the Department of Corrective Services to minimise the trade in drugs in the prison environment.

At an early age the deceased had begun to use illicit drugs and came to the attention of the law. The deceased engaged in drug rehabilitation but after the suicide of his father the deceased relapsed into heavy drug use. His behaviour became erratic and volatile and he continued to commit criminal offences, eventually serving a number of prison terms. After being released on parole in November 2006 the deceased committed further offences and his parole was suspended and he was taken back into custody. The deceased was denied release on parole in June 2010 and remained in prison until his death.

The deceased’s medical records showed that throughout his terms of incarceration he became increasingly unwell, including his Crohn’s disease which had a long-term effect on the deceased’s health. In the last months of the deceased’s life it was noted that the deceased was becoming significantly more ill. Contrary to the recommendation of the prison doctors, the deceased declined to be housed in the prison infirmary. He also declined to follow other medical advice on occasion.

The deceased was prescribed a number of medications and in addition to these prescribed medications; it was not unknown for the deceased to access other drugs within the prison system. Prison records indicate that the deceased received 16 prison charges against him, many of the offences were drug related, including being found in possession of syringes, smoking implements and cannabis, as well as secreting medication that was issued to him.

Evidence was provided to the Court from the forensic pathologist who conducted the post mortem examination and expert witnesses gave evidence in respect to the deceased’s possible cause of death. The Coroner determined that the deceased died as a result of multiple drug toxicity and death arose way by way of Accident.

The deceased’s mother raised a number of concerns in respect to the care of the deceased and these issues were explored during the inquest by the Coroner. At the conclusion the Coroner was satisfied the deceased received a high standard of medical care, at a minimum as good as what he would have expected to receive if he was not incarcerated. The Coroner was satisfied that there was nothing that the Department of Corrective Services did or failed to do that contributed to the deceased’s death.

Catch Words: Death in Custody : Drugs in Prison Environment : Accident.


Last updated: 13-Feb-2024

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