Coroner's Court of Western Australia

Inquest into the Death of Shane Reynold NARRIER

Inquest into the Death of Shane Reynold NARRIER

Delivered on :14 September 2023

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Shane Reynold Narrier (Shane) was 40 years old when he died on 5 June 2020 at St John of God Midland Hospital (SJOGMH). He was a sentenced prisoner and was in the care of the CEO of the Department of Justice at the time of his death. As he was a person held in care, his death was subject to a mandatory inquest.

Shane commenced his term of imprisonment on 6 December 2019, and his earliest eligible date for parole was 30 August 2020. From 7 January 2020 he was incarcerated at Acacia Prison (Acacia).

On 27 May 2020, Shane sent an electronic message using Acacia’s Custody Messaging System requesting an appointment with a prison doctor as he had been getting “chest pains”. A prison nurse read Shane’s message later that day and an appointment was administratively made for Shane to see a prison nurse on 31 May 2020. Shane did not attend that appointment and it was later rescheduled for 11 June 2020.

On the morning of 5 June 2020, Shane was sitting on a small wall in an outside area of the prison block where his cell was situated. He suddenly collapsed and fellow prisoners who went to assist him noticed he was struggling to breathe.  Prison officers and medical staff responded quickly and first aid was provided before Shane was taken to the medical centre at Acacia.

As he was being treated at the medical centre, Shane became unresponsive. CPR was commenced and a call was made for an ambulance to attend. Despite intensive medical treatment from Acacia medical staff and ambulance officers, Shane’s heart stopped beating as he was being taken by ambulance to SJOGMH. Despite ongoing resuscitation by hospital staff, Shane died shortly after midday on 5 June 2020.

The cause of Shane’s death was coronary artery atherosclerosis, and his death occurred by way of natural causes.

The Coroner found that Shane’s complaint of chest pains on 27 May 2020 clearly identified a potentially serious medical issue that should have warranted an immediate medical response. That response, in accordance with Acacia’s policy, required an immediate medical examination. As that did not occur, the Coroner found a serious error had been committed by the prison nurse in not making urgent arrangements for Shane’s chest pains to be promptly examined.

The Coroner also found that when Shane did not attend his scheduled appointment with a prison nurse on 31 May 2020, there should have been an immediate follow-up with every effort made to have him medically examined. That did not occur, which the Coroner described as a missed opportunity.

In addition, the Coroner was satisfied Shane’s treatment and care with respect to his undiagnosed heart disease which caused his death was sub-optimal even before he complained of chest pains for the first time on 27 May 2020. Furthermore, the Coroner found that had Shane’s complaint been correctly actioned on 27 May 2020, there was a likelihood he would not have died from his heart disease.   

Catch Words : Mandatory Inquest: Death in Custody: Natural Causes: Failure to Correctly Action a Complaint of Chest Pains

Last updated: 6-Oct-2023

[ back to top ]