Coroner's Court of Western Australia

Inquest into the Death of Valerie KELLY

Inquest into the Death of Valerie KELLY

Delivered on : 2 April 2020

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

In order to ensure that referrals of prisoners to external agencies, made by prison clinical staff, are appropriate actioned, the Department should consider using its health records system (EcHO) to generate automatic reminders to clinical staff. These reminders would prompt clinical staff to check whether an appointment had been received from the external agency for the prisoner and/or whether the appointment had been attended by the relevant prisoner.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Valerie Kelly (Ms Kelly) died at Royal Perth Hospital on 24 September 2016. At the time of her death she was being held in custody on remand at Bandyup Women’s Prison (the Prison) and was 67 years of age.

The inquest hearing focused on the quality of the supervision, treatment and care Ms Kelly received while she was in custody.

Ms Kelly was arrested and charged with her sister’s murder on 25 June 2015. When she was admitted to the Prison on 26 June 2015, her medical history was found to include: ischaemic heart disease, type-2 diabetes, alcohol related liver disease, chronic subdural haematomas, high cholesterol, osteoarthritis, osteoporosis, emphysema and low platelet levels. She disclosed a long standing issue with alcohol use and her surgical history included: the removal of her gallbladder, coronary artery bypass grafts and a total knee replacement.

On 23 December 2015 Ms was referred to the hepatology clinic at Fiona Stanley Hospital (FSH) after blood tests showed she had a low blood count that was possibly related to liver disease. Records show that an appointment was made for Ms Kelly to see a liver specialist at FSH on 10 February 2016, but there is no record that notification of that appointment was received by the Prison. Unfortunately prison medical staff at the Prison did not follow up on the referral. On 21 April 2016, Ms Kelly was referred to the gastroenterology clinic at FSH for a colonoscopy to investigate her reported rectal bleeding. She was placed on a waitlist and the procedure was scheduled for 14 June 2016.

At about 3.55 pm on 2 June 2016, Ms Kelly fell heavily in the doorway of her cell. She was taken to Royal Perth Hospital, where she was found to have fractured the neck of her left femur that was surgically repaired on 4 June 2016. During her admission, Ms Kelly was treated for a decline in her brain function caused by severe liver disease (hepatic encephalopathy), which caused her to become delirious and agitated and predisposed her to pneumonia.

On 17 June 2016, Ms Kelly was reviewed by the palliative care team at Royal Perth Hospital. Although her prognosis was uncertain, it was felt that her condition would deteriorate over the following few weeks. Ms Kelly was not a suitable candidate for hospice care because of her variable mental state, but she was regularly reviewed by the palliative care team. On 13 July 2016, all unnecessary medications were ceased. Ms Kelly received palliative care and remained largely unconscious over the next few weeks and her condition continued to deteriorate until her death on 24 September 2016.

The Coroner found that Ms Kelly’s clinical care at Royal Perth Hospital was of a high standard and was satisfied that the supervision, treatment and care that she received while she was in custody was adequate.

Catch Words : Death in Custody : Medical issues during Incarceration : Falls Risk : Rectal Bleeding : Natural Causes

Last updated: 17-Apr-2020

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