Coroner's Court of Western Australia

Inquest into the Death of Stuart William DUGAN

Inquest into the Death of Stuart William DUGAN


Delivered on : 15 January 2021

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Dugan was a sentenced prisoner at Acacia Prison when he was diagnosed with terminal lung cancer in early 2017. He received palliative care until his death on 4 May 2017.

Mr Dugan was sentenced on 29 April 2011 to a term of 14 years’ imprisonment . His sentence commenced on 1 February 2010. He served the majority of his sentence at Acacia Prison. Upon entering the prison system Mr Dugan was noted to have no significant or psychiatric concerns other than a shoulder injury. Mr Dugan received treatment for his shoulder and was referred to a specialist. Mr Dugan did not have any health issues again until 27 July 2015 when he presented with a painful tooth.   Mr Dugan was later admitted for elective inguinal hernia repair at Fremantle Hospital on 15 July 2016.

On 9 December 2016 Mr Dugan was reviewed by a prison medical officer. He complained of an intermittent cough with sputum after having ceased smoking six months earlier in July 2016. He was prescribed antibiotics, routine blood tests were ordered and a review was planned for four weeks. He was not seen again by health services staff until 31 January 2017 when he was reviewed by a prison nurse. At this time he reported that he had been coughing up blood for the last couple of weeks, he was experiencing chest pain and his observations were normal apart from a raised pulse. Various tests were ordered but Mr Dugan had not undergone urgent chest x-ray before his condition seriously deteriorated.

On 19 February 2017, as a result of Mr Dugan being unable to breathe properly and coughing up thick blood stained sputum, it was decided by prison medical staff Mr Dugan should be transferred by ambulance to hospital. Mr Dugan was diagnosed with locally advanced inoperable left upper lobe cancer of the lung. He was considered to be a poor surgical candidate given his functional status, his tumour was too big for radiotherapy and he was felt to be currently too weak for chemotherapy. Palliative radiotherapy was considered but was deemed not suitable due to potential damage to lung tissue.

Mr Dugan was discharged from hospital to Casuarina Prison on 2 March 2017. Once at the Casuarina Infirmary nursing staff expressed concerns that they were not able to manage his care safely in the infirmary. His welfare was assessed by a prison medical officer who organised a transfer by ambulance to St John of God Midland Hospice. On 7 March 2017 St John of God Hospice staff wished to discharge Mr Dugan back to the Casuarina prison infirmary as they believed he was doing well and was self-caring. When he did return to Casuarina Prison infirmary it was immediately apparent to the prison nursing staff that they did not have the ability to manage his care in the prison. A decision was made for Mr Dugan to be sent by ambulance to Fiona Stanley Hospital. Arrangements were eventually made to transfer Mr Dugan to Kalamunda Hospice on 6 April 2017 for end of life care. He remained at the hospice and received palliative care until his death on the morning of 4 May 2017.

The Deputy State Coroner was satisfied that Mr Dugan’s death was unlikely to have been preventable even if diagnosed earlier, and accepted that his treatment, supervision and care while in prison was satisfactory. However, the Deputy State Coroner noted that the prison system could be more proactive in health monitoring for prisoners, which might make opportunities for earlier diagnosis of serious health conditions. The Court heard the Department and Acacia Prison has made significant changes to its processes and procedures in its health services since Mr Dugan’s death.

Catch Words : Death in custody : Supervision, Treatment and Care : Health Assessments and Follow Up : End of Life Care : Natural Causes

Last updated: 27-Jan-2021

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