Deceased
Damien Matthew Purnell
Demographics
47y, male
Coroner
Coroner Linton
Date of death
2018-08-20
Finding date
2020-11-04
Cause of death
organ failure following cardiorespiratory impairment in a man with arteriosclerotic heart disease and recent use of drugs (synthetic cannabinoids)
AI-generated summary
Damien Matthew Purnell, a 47-year-old prisoner with a long history of polysubstance abuse and undiagnosed coronary artery disease, collapsed in his cell after smoking synthetic cannabinoids (Kronic). Despite immediate resuscitation by prison staff and ambulance paramedics, he suffered irreversible hypoxic brain injury and died three days later. Synthetic cannabinoids triggered a fatal cardiac arrhythmia in a man with 65% stenosis of the left anterior descending coronary artery. While prison medical care was high-standard, the case highlights the inherent dangers of synthetic cannabinoids—particularly in patients with undiagnosed cardiac disease—and the challenges of preventing illicit drug access in custodial settings. The preventability hinged on preventing the drug entering the prison, not on clinical management post-collapse, which was exemplary.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
[2020] WACOR 35 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON HEARD : 15-16 SEPTEMBER 2020 DELIVERED : 4 NOVEMBER 2020 FILE NO/S : CORC 135 of 2018
DECEASED : PURNELL, DAMIEN MATTHEW Catchwords: Nil Legislation: Nil Counsel Appearing: Sgt L Houisaux assisted the Coroner.
Mr S Pack (SSO) appeared for the Department of Justice.
Case(s) referred to in decision(s): Nil
[2020] WACOR 35 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Coroner, having investigated the death of Damien Matthew PURNELL with an inquest held at Busselton Magistrates Court on 15 to 16 September 2020, find that the identity of the deceased person was Damien Matthew PURNELL and that death occurred on 20 August 2018 at Bunbury Regional Prison, from organ failure following cardiorespiratory impairment, in a man with arteriosclerotic heart disease and recent use of drugs in the following circumstances:
Evidence suggests he continued to use drugs whilst in prison, despite being prescribed methadone to help manage his drug addiction while in custody.
On Friday, 17 August 2018, Mr Purnell was released from his cell at 7.30 am. He received his usual morning dose of methadone and ate breakfast before being locked back into his cell due to prison staff training commitments. Sometime around 11.00 am, prison staff found Mr Purnell collapsed on his bunk in his cell. He was not breathing, so they commenced CPR and called for an ambulance to attend. Mr Purnell was taken by ambulance to Bunbury Regional Hospital where resuscitation was continued before Mr Purnell was admitted to the Intensive Care Unit. His prognosis was poor.
On 19 August 2018 Mr Purnell’s condition deteriorated and testing confirmed he was brain dead. Organ donation was arranged, as per his family’s wishes.
A post mortem examination found evidence of pre-existing heart disease and toxicology analysis detected synthetic cannabinoids, as well as his prescribed methadone. Synthetic cannabinoids are associated with an effect on the heart and are more likely to be dangerous to anyone who has a preexisting heart problem. Mr Purnell was found to have died of organ failure after a cardiorespiratory arrest in the context of his heart disease and recent use of drugs.
A prisoner told investigators that Mr Purnell appeared ‘stoned’ before lock up and he was aware Mr Purnell kept a secret stash of the synthetic cannabinoid ‘Kronic’ in his cell to use during lock up. A search of Mr Purnell’s cell after his death found a quantity of a synthetic cannabinoid and a modified smoking implement containing residue. It is unclear exactly how he managed to access the drug, although it is well known that prisoners engage in the illicit trade of drugs despite the significant efforts of prison staff to prevent drugs entering prisons unlawfully.
By virtue of being a sentenced prisoner at the time of his death, Mr Purnell was a ‘person held in care’ for the purposes of the Coroners Act 1996 (WA). In such circumstances, a coronial inquest is mandatory.1 I held an inquest at the Busselton Courthouse on 15 and 16 September 2020. At the 1 Section 22(1)(a) Coroners Act.
[2020] WACOR 35 inquest, extensive written material was tendered in relation to the investigations into Mr Purnell’s death conducted by WA Police and the Department of Corrective Services,2 and a number of witnesses were called to give evidence in person.
The only real issue in the inquest was the question of his supervision, given he was able to access an illicit substance within the prison, as well as whether his intoxication should have been detected at an earlier stage.
Mr Purnell’s stepfather was allegedly violent and Mr Purnell reportedly suffered significant trauma and abuse from an early age. He ultimately left home at the young age of 13 years and began working as a farm hand from 14 years of age.3
Not surprisingly, given his childhood history, Mr Purnell began using illicit drugs at a young age, and was said to have first started using cannabis at 13 years of age. He had been prescribed dexamphetamine for ADHD from the age of 5 years, but this was ceased when he was 15 years old. Mr Purnell reported that his life quickly unravelled thereafter and he moved on to amphetamines, opiates and benzodiazepines He also became involved in criminal behaviour at a young age.4
As an adult, Mr Purnell was in a number of relationships. He had three children with his first partner and he also reportedly had a son with another partner in 2000. He was in a long-term relationship with Jacinta Cooper at the time he went into prison and leading up to his death and they had one son together.5
Between 2005 and 2010 Mr Purnell was on the Community Pharmacy Opiate Program and was prescribed methadone but this was ceased in 2010 2 Exhibits 1 – 3.
3 Exhibit 1, Tab 33.
4 Exhibit 1, Tab 33; Exhibit 3, Tab 24.
5 Exhibit 1, Tab 10 and Tab 33.
[2020] WACOR 35 because he went on the run from police.6 He began using illicit substances again and also acquiring prescription medications off the street.7
In July 2011 Mr Purnell was admitted to Bunbury Hospital after an overdose of morphine. He commenced naltrexone in 2011 and was later prescribed Suboxone (buprenorphine and naloxone) to treat his opioid addiction.
In February 2018 Mr Purnell accidentally overdosed on Fentanyl patches, a very strong synthetic opioid. He suffered a respiratory arrest and required resuscitation and administration of the opioid reversal agent naloxone. He was taken to Busselton Hospital but discharged himself against medical advice.8
On 19 February 2018 Mr Purnell underwent a mental health assessment at Busselton Community Mental Health Clinic. He was noted to be paranoid with a history of polysubstance abuse. He admitted he had been misusing opiates for a prolonged period. His paranoid symptoms were thought to be more overvalued ideas than delusional and he was advised to wean himself off his pregabalin/Lyrica medication as it was felt he might be experiencing pregabalin intoxication.9
Also in February 2018 concerns were raised about Mr Purnell’s cognitive functioning and the possibility of early onset dementia so he was seen by the Neurology Department at Fiona Stanley Hospital. Following various testing it was felt unlikely that he was suffering a dementing process.10
7 Exhibit 3, Tab 24.
8 Exhibit 3, Tab 33.
9 Exhibit 3, Tab 24 and 33.
10 Exhibit 3, Tab 24.
[2020] WACOR 35 prison population. Mr Purnell was taken to Bunbury Regional Prison that day to commence serving his sentence.11
He had also exhibited drug-seeking behaviour in the past. During the prison nurse’s initial assessment of Mr Purnell on this admission to prison, he was pleasant and cooperative but extremely anxious, with an almost constant tremor noted in his right arm and leg. His recent presentation to Busselton Hospital for fentanyl overdose was noted and also his past history as a registered drug addict. He reported he had last used intravenous methylamphetamine approximately one month before. He denied any thoughts of self-harm or suicidal ideation and signed an information release so that his recent health care records could be urgently obtained from Busselton Clinic and Busselton Hospital. Mr Purnell was prescribed drug withdrawal medications via an e-consult with the doctor and appointments were made for Mr Purnell to have a mental health review and medical review.12
Mr Purnell was known to be allergic to bee stings and fish, so he was issued with an Epipen in prison. He was also an asthmatic, so he was issued with a Ventolin inhaler.13
On 22 March 2018 Mr Purnell received drug counselling from a mental health nurse with the prison’s Co-morbidity Team, Nurse Mill. He was very anxious and stressed despite being on Valium for withdrawal. He was assessed as having an opiate use disorder, stimulant use disorder and chronic substance abuse. His drug screen was noted to be positive for buprenorphine, THC and benzodiazepines. He reported being prescribed Avanza and Oxazepam for his depression and anxiety. It was noted that he planned to remain on methadone in the community and he was considered to be a candidate for the methadone programme. It was felt his paranoid delusions could be related to his substance abuse or might be due to an underlying mental health illness, so assessment by a psychiatrist was required as well as ongoing mental health support.14
A doctor conducted an administrative review on 23 March 2018 to confirm his medical history and recent prescriptions before updating his prison medication prescriptions.15 11 Exhibit 1, Tab 2 and Tab 33.
12 Exhibit 3, Tab 33.
13 Exhibit 1, Tab 2, p. 9.
14 Exhibit 3, Tab 33.
15 Exhibit 3, Tab 33.
On 29 March 2018 Mr Purnell had a telehealth appointment with Dr Hames for consideration of recommencing methadone in prison as he had been on Suboxone previously. It was noted that he was taking Seroquel (quetiapine) for drug related paranoia. Mr Purnell advised he had been taking Suboxone and using heroin if he couldn’t get Suboxone while in the community. He had also abused his prescription medications diazepam and oxazepam. It was decided that he could recommence methadone, continue using Seroquel for two months and should start reducing his diazepam dose.16
Mr Purnell was reviewed again by a mental health nurse on 5 April 2018 prior to recommencing methadone. He claimed he had not used any illicit drugs whilst in prison as he didn’t want to jeopardise his hepatitis C treatment he had apparently done recently. He reported that he needed methadone treatment to prevent him relapsing and signed the necessary paperwork to recommence methadone. He received his first methadone dose on 6 April 2018 and was reviewed daily for the next week and then regularly thereafter to ensure he was stabilising on his methadone and that his dose was properly titrated.17
He noted Mr Purnell appeared to be suffering longstanding psychotic symptoms against a background of polysubstance abuse and personality disorder. He wanted regular Valium prescribed. Dr De Klerk identified no clear thought disorder and no clinically impaired cognition. The impression was of long standing psychotic symptoms against a background of polysubstance abuse and previously diagnosed personality disorder. They discussed the benefits of antipsychotic medication and at the end of the consultation Dr De Klerk increased Mr Purnell’s dose of quetiapine, an antipsychotic.18
However, from 7 May 2018 Mr Purnell refused to take his morning quetiapine as he felt it made him ‘too out of it’. Dr De Klerk attempted to review Mr Purnell on 17 May 2018 to discuss his resistance to taking his medication but Mr Purnell refused to speak to him, apparently telling a prison officer that Dr De Klerk gave him “shit medication.”19 His morning dose of quetiapine was consequently ceased, although he continued with his evening dose.
On 11 June 2018 a case conference was held with Dr De Klerk and Nurse Mill. Dr De Klerk noted that Mr Purnell had indicated he didn’t like him and didn’t want to see him. Dr De Klerk noted that Mr Purnell had 16 Exhibit 1, Tab 33.
17 Exhibit 1, Tab 33.
18 Exhibit 1, Tab 33.
19 Exhibit 1, Tab 33, p. 16.
[2020] WACOR 35 high mental health needs and needed to remain on the prison Mental Health Register for at least a quarterly review by a psychiatrist and interim review by a mental health nurse. He also required annual metabolic monitoring.
On 26 June 2018 Mental Health Nurse Mill reviewed Mr Purnell again and counselled him about drug abuse. At that time he was taking his top dose of 40mg of methadone daily and said it wasn’t ‘holding’ him. He reported he was illicitly buying two tablets of 150mg of pregabalin (Lyrica) every second day to use for pain relief. The consequences and risks of this behaviour were discussed with him and he requested to see the medical officer so he could get the pregabalin formally prescribed. It appears this appointment did eventually occur, but not until 14 August 2018. His mental health status appeared stable, although he was worried about the outcome of a State appeal against this sentence, and also had negative thoughts about his girlfriend, which he acknowledged were probably not true. He was talking to his girlfriend every day and trying to be more positive about their relationship.20
On 14 August 2018 Dr Hames reviewed Mr Purnell, who claimed he had not used intravenous drugs while in prison. He was taking his 40mg of methadone as prescribed but felt this was not quite enough to keep him comfortable. Dr Hames advised the dose of methadone should be titrated gradually up to 60mg. On 4 July 2018 Mr Purnell’s blood results had shown an abnormal liver function test but a negative hepatitis C viral load.
Based on these results, Dr Hames referred Mr Purnell for a repeat blood test and an abdominal ultrasound scan to further assess his liver. Mr Purnell also complained of intermittent rectal bleeding over the last couple of years.
Rectal examination was normal and it was suggested that he should be referred for a colonoscopy and have his iron level and coagulation profile checked. Mr Purnell repeated his request to be prescribed pregabalin and explained he suffered nerve pain and hypersensitivity in his hand due to a nerve graft after a dog bite many years before. Dr Hames recommenced pregabalin to manage his nerve pain.21
21 Exhibit 1, Tab 33.
22 Exhibit 1, Tab 33.
Mr Purnell had been housed in a cell in House D, a self-care unit, with another prisoner, Prisoner Khew, for the three weeks before his death. The cells were unlocked between 7.30 and 8.00 am each day and the prisoners were usually able to move freely within the unit, other than stopping for musters to conduct head counts, until locked in their cells at night. They could cook for themselves in the unit’s kitchen and Mr Purnell’s cellmate apparently often cooked for both of them. They could also work within the prison, and Mr Purnell had worked as a cleaner and as a hairdresser.23
On Friday, 17 August 2018, Mr Purnell was released from his cell at 7.30 am. Mr Purnell collected a gratuities check at some stage and was given his last dose of methadone at 8.10 am and Lyrica (pregabalin).
Mr Purnell’s cellmate recalled Mr Purnell usually looked ‘drunk’ after receiving his methadone, and he appeared the same on this occasion.
Mr Purnell ate his breakfast and shared a coffee with another prisoner, Prisoner Offer, in his cell. Prisoner Offer noticed that Mr Purnell’s face appeared red and he looked “funny”24 that morning and kept rubbing his face. When he asked Mr Purnell if he was alright, Mr Purnell said he “just needed to have a sleep.”25 There was some hearsay evidence from other prisoners that Prisoner Offer intended to smoke Kronic with Mr Purnell before lockdown, but this was denied by Prisoner Offer. He said they shared a cup of coffee in Mr Purnell’s cell and he and Mr Purnell made plans to walk around the oval after they were released from lockdown at lunchtime, before Prisoner Offer returned to his own cell.26
At around 8.40 am, Mr Purnell and his cell mate were locked back in their cell due to staff training commitments.27 A Prison Officer who saw Mr Purnell at the time his cell was locked, Officer Sharon Pedrick, recalled she asked him how he was and Mr Purnell told her he was “all good.”28 He appeared fine and was smiling.29
Prisoner Khew told police that after lockdown Mr Purnell was sitting at a table playing Xbox and smoking. Prisoner Khew fell asleep and did not wake again until prison officers entered their cell.30 23 Exhibit 1, Tab 2.
24 Exhibit 1, Tab 30.
25 Exhibit 1, Tab 30.
26 T 9; Exhibit 1, Tab 17.
27 Exhibit 1, Tab 2.
28 T 22; Exhibit 1, Tab 2, p. 6 and Tab 12.
29 Exhibit 1, Tab 12.
30 Exhibit 1, Tab 2, p. 6.
Mr Purnell was required to attend court via video link that day in relation to an appeal. Two Prison Officers, Officers McIlwraith and Johnson, went to his cell to escort him to the video link facilities. After doing the appropriate checks, including calling out through the hatch, which produced a response from Mr Purnell’s cellmate but not Mr Purnell, they unlocked the cell and entered. When the officers entered Mr Purnell’s cell at about 10.50 am, he was lying on his stomach on the top bunk. He did not respond to verbal and physical attempts by the officers to get his attention. Officer McIlwraith then checked his breathing and quickly realised he was not breathing and unresponsive.31
Officer McIlwraith called a Code Red emergency, which requires an immediate response, over the radio. The two prison officers, with the assistance of another officer who had arrived quickly, then moved Mr Purnell from his top bunk to the floor outside the cell to have better access to him. They commenced resuscitation at about 10.55 am after they ascertained he was not breathing.32
Other custodial staff arrived to assist, bringing with them emergency resuscitation equipment. Health services staff also attended with their own emergency medical equipment at about 11.03 am. Clinical Nurse Julie Clarke indicated she went to the scene with two other nurses accompanied by the resuscitation equipment. They noted on their arrival that Mr Purnell was cyanotic, not breathing and his pupils were unreactive to light. Airway management was commenced and his colour and oxygen rates improved.
The defibrillator was applied at 11.05 am but it advised that no shock was to be administered, so they continued with CPR.33
An ambulance had been requested to attend and ambulance paramedics arrived on scene at approximately 11.17 am and took over resuscitation attempts shortly after. They managed to get Mr Purnell’s circulation back and once he was stable the ambulance departed the prison at 11.41 am.34 Mr Purnell was taken by ambulance to Bunbury Regional Hospital and his next of kin were notified.35
On 19 August 2018 Mr Purnell was added to the prison’s Terminally Ill Module as a Stage 4 prisoner, indicating his death was considered imminent.36 31 T 10, 40 - 41; Exhibit 1, Tab 15; Exhibit 2, Tab A – Death in Custody Review Report, Executive Summary.
32 Exhibit 2, Tab A – Death in Custody Review Report, Executive Summary.
33 T 14 – 17; Exhibit 3, Tab 33.
34 T 11; Exhibit 3, Tab 33.
35 Exhibit 2, Tab A – Death in Custody Review Report, Executive Summary; Exhibit 3, Tab 33.
36 Exhibit 3, Tab 33.
On 28 August 2018 a forensic pathologist, Dr Cooke, performed a post mortem examination on Mr Purnell. The examination showed changes of recent medical treatment, including organ donation. There was enlargement of the heart, with some thickening of the heart muscle (mild left and right ventricular hypertrophy) and a localised area of narrowing of one of the arteries on the surface of the heart (focal coronary arteriosclerosis – 65% narrowing, left anterior descending coronary artery). Microscopic examination also showed some scarring of the heart and superimposed changes of recent myocardial ischaemia. The lungs were congested, with early pneumonia. The brain showed swelling and softening and neuropathology examination of the brain showed hypoxic brain injury.38
Dr Cooke noted that the findings of myocardial ischaemia, pneumonia and hypoxic brain injury can all follow a period of cardiorespiratory impairment.39
Post mortem toxicology analysis was significant. It demonstrated the presence of methadone at a normal level, as well as two types of synthetic cannabis. Dr Cooke noted that although synthetic cannabis agents are a relatively new type of designer drug, it is becoming increasingly evident that they may be associated with an effect on the heart, causing an increased heart rate and possible cardiac arrest. The Alcohol and Drug Foundation warns in information available online that synthetic cannabinoids are likely to be more dangerous to anyone who has a preexisting heart problem, it is relevant that Mr Purnell had some pre-existing heart disease.40
Dr Cooke concluded that it seemed that Mr Purnell sustained a period of impaired cardiorespiratory function (possibly a cardiorespiratory arrest) following the use of drugs and in the presence of some pre-existing heart disease, and thereby sustained hypoxic/ischaemic injury to his brain and heart muscle, terminally developing pneumonia and leading to his death.41 37 T 11; Exhibit 3, Tab 33.
38 Exhibit 1, Tab 7A and Tab 8.
39 Exhibit 1, Tab 7A.
40 Exhibit 1, Tab 7A and Tab 9.
41 Exhibit 1, Tab 7A.
Dr Cooke ultimately formed the opinion the cause of death was organ failure following cardiorespiratory impairment in a man with arteriosclerotic heart disease and recent use of drugs.42
In respect to the particular role that synthetic cannabinoids played in Mr Purnell’s death, Professor David Joyce, a clinical pharmacologist who often provides expert evidence to the court on matters where deaths appear to have been drug related, was able to provide additional expert evidence to the Court about the effect that the illicit drugs had upon Mr Purnell, in combination with his pre-existing heart disease and methadone dose.
Professor Joyce observed that the methadone dose prescribed to Mr Purnell and the introduction of a dose of pregabalin would not give a reason for concern that those drugs on their own would bring about lethal drug toxicity, particularly given Mr Purnell’s history of treatment on methadone and the well-known effects of these drugs.43 However, the synthetic cannabinoids were in a different category. Professor Joyce explained that there is no comprehensive toxicology information on these substances but they are known to have class effects, with the potential to cause adverse effects on the heart and circulation and potentially lead to death. Professor Joyce noted that Mr Purnell had established coronary artery disease, with a 65% obstruction of one of the main coronary arteries as well as fibrotic changes, and there are known associations between synthetic cannabinoids and cardiac complications leading to death, particularly sudden death.44
Professor Brown advised that of the specific compounds found in Mr Purnell’s system after his death, a close relative of the Cumyl compound has been associated with sudden cardiac death.45
In conclusion, based upon the recognition that Mr Purnell was in a category of patient group that is known to have had higher risk of a lethal outcome from synthetic cannabinoids (namely male, his age and his established cardiac disease) he suffered a sudden cardiac death, which is one of “the commonest ways in which cardiac toxicity of synthetic cannabinoids generally manifests itself”46 and at least one of the drugs found during his toxicology analysis was from a family with a proven capacity to cause sudden cardiac death, Professor Joyce felt the most likely reason for his death was a cardiac arrhythmia caused by the synthetic cannabinoids.47 42 Exhibit 1, Tab 7A.
[2020] WACOR 35 Therefore, Professor Joyce supported the proposed cause of death formulated by Dr Cooke.48
The investigation, which was ultimately led by Senior Constable Ross Mullaniff from the Coronial Investigation Squad, was very comprehensive and a detailed report was later provided to the Coroner’s Court. In addition, Senior Constable Mullaniff, gave evidence at the inquest.
Initially, on 17 August 2018 while Mr Purnell was still on life support, a number of detectives from Bunbury Detectives Office and a forensics officer attended Bunbury Prison at around 4.00 pm to conduct a preliminary investigation. Mr Purnell’s cell had been locked and taped off with crime scene tape by prison staff. His cell was in a self-care house with a total of 7 cells housing 12 prisoners.49
The police officers entered the cell and took photographs and a video and seized some items of bedding and an asthma inhaler.50
On 18 August 2018 Mr Purnell’s cell was searched again, this time by prison officers. They located improvised drug smoking implements and a substance believed to Kronic. Attempts had been made to conceal them in the cell. There was residue on the smoking implements to indicate it had been used. Mr Purnell’s cellmate denied any knowledge of the items.51 The prison conducted a wider search and also found Kronic in the property of another prisoner. They also investigated the allegation that another prisoner had experienced a seizure after using Kronic a week or so before Mr Purnell’s death, which appeared to be substantiated.52
Mr Purnell’s cell had been searched on six occasions between 6 June 2018 to 17 June 2018 and no similar items had been located. He had undergone 46 separate alcohol and substance tests while at Bunbury Prison, two of which were targeted, and all of them except for his first test after admission were negative.53 However, while I note the testing refers to cannabis
49 T 8; Exhibit 1, Tab 3.
50 Exhibit 1, Tab 2, p. 2.
51 Exhibit 1, Tab 39; Exhibit 2, Tab A – Death in Custody Review Report, Executive Summary and Tab 15 and Tab 21; Exhibit 3, Tabs 4 - 5.
52 Exhibit 2, Tab 15 and Tab 20.
53 Exhibit 2, Tab A – Death in Custody Review Report, Executive Summary.
[2020] WACOR 35 metabolites, it is unclear whether such testing would identify all synthetic cannabinoids. I note the expert evidence was that synthetic cannabinoids are rarely identified in standard screening procedures and require more targeted analysis.54
The plant material and substance on the smoking implements seized from Mr Purnell’s cell were analysed and found to be SGT-263 and CUMYLPEGACLONE, both synthetic cannabinoids. These same substances were detected in Mr Purnell’s blood after his death.55
Following Mr Purnell’s death, on 28 and 29 August 2018 police officers went to Bunbury Prison and interviewed prisoners, prison officers and medical staff and perused relevant prison documentation. On speaking with some prisoners, it appeared a story was circulating that Mr Purnell had suffered an allergic reaction to fish sauce. It was suggested he had eaten it in his breakfast, which was made by his cell mate, Prisoner Khew.
Mr Purnell had a documented allergy to fish sauce and bee stings in his medical records. Prisoner Khew was asked about this rumour and he denied this occurred. He stated he had given Mr Purnell only an egg and bacon roll to eat that morning. There was no evidence found to substantiate the rumour that Mr Purnell had been inadvertently fed something that caused an allergic reaction.56
Mr Purnell was described by many prisoners as often appearing drug affected. He was known to take prescribed methadone through the prison health system and smoke ‘roll up’ cigarettes heavily, which could be bought in the prison shop. In addition, some prisoners provided information that Mr Purnell was known to smoke the synthetic cannabis Kronic constantly and to take any other prescription medication he could “get his hands on.”57 It was said that he would make a smoking implement out of any material he could find.58
One prisoner told investigators that Mr Purnell appeared ‘stoned’ before lock up and he had been told that Mr Purnell had a stash of Kronic specifically for use during the lock up period on Friday mornings.59 Another prisoner recalled being told that Mr Purnell had a bowl of Kronic to smoke before lockdown the morning that he died.60 Other prisoners provided similar information. Despite a large number of prisoners being interviewed by police, the investigators were unable to determine exactly 54 Exhibit 1, Tab 54.
55 Exhibit 1, Tab 2, p. 12 and Tab 54; Exhibit 2, Tab 22.
56 T 9; Exhibit 1, Tab 2, p. 3 and Tab 17.
57 Exhibit 1, Tab 2, p. 3 and Tab 18.
58 Exhibit 1, Tabs 18 – 31.
59 T 9; Exhibit 1, Tab 2, p. 3 and Tab 18.
60 Exhibit 1, Tab 19.
[2020] WACOR 35 how Mr Purnell obtained the synthetic cannabinoids, but the evidence strongly suggested it was not his first time using it and there had been unsubstantiated allegations in the past that he had received illicit substances from visitors.61 Unfortunately, on this occasion it had a serious effect on Mr Purnell that he did not appear to have experienced before.
I am aware from other coronial matters that synthetic cannabinoids are a subgroup of what are labelled new psychoactive substances or ‘NPS’ (designed to mimic established illicit drugs). In order to resemble natural cannabis, and to allow it to be smoked like natural cannabis, the synthetic compound is usually sprayed onto plant material. Synthetic cannabinoids are reportedly generally manufactured in clandestine laboratories overseas, rather than in clandestine laboratories in Australia, and are often purchased online and delivered to Australia via mail.63 In this case, the synthetic cannabinoids made their way into Bunbury Prison by an unknown means.
There appears to have been a misconception in the past that, because they were advertised as legal, synthetic cannabinoids were also safe. However, since that time it has become clear that they are often highly toxic.
Published reviews highlight adverse effects including psychosis, seizures, coma, paranoia, tachycardia, hypertension, acute coronary syndrome, arrhythmia, myocardial infarction and acute kidney injury and death.64
Kronic was one such synthetic cannabinoid, which became prohibited on 17 June 2011 along with a number of other synthetic cannabinoids. Later, in 2015, the Western Australian government introduced new provisions into Misuse of Drugs Act 1981 (WA) covering psychoactive substances more generally, in order to cover the field. The new provisions explicitly banned the sale, supply, manufacture, advertising or promotion of any psychoactive 61 Exhibit 2, Tab 19.
64 Exhibit 1, Tab 54.
[2020] WACOR 35 substance that was not already captured by existing legislation. These provisions came into effect on 18 November 2015, well prior to the death of Mr Purnell.65
Since the introduction of that legislation, the Forensic Science Laboratory at ChemCentre has noted a reduction in the detection of synthetic cannabinoids, although they do continue to be detected in coronial cases and it is apparent that new types of synthetic cannabinoids continue to emerge.
Dr David Brown, a chemist at the ChemCentre of Western Australia, gave evidence at the inquest that synthetic cannabinoids are “typically very potent drugs”66 but they are not always easily detected in routine screening and often require targeted analysis to detect them, which is done by reference to other information that suggests it is appropriate. The target analysis in the case of Mr Purnell was undertaken after the smoking implement and drugs were found during the cell search, and the chemists were able to identify the synthetic cannabinoids he had taken as the ChemCentre already had the necessary reference materials for those substances, although that is not always the case for some of the newer types.67 Dr Brown advised that ChemCentre has noted a drop-off in cases of detection of synthetic cannabinoids in WA since their peak from 2014 to 2016 (with the first case recorded in 2010) and the diversity of types of synthetic cannabinoids has also reduced, but they are still seeing new synthetic cannabinoids even now.68
Dr Brown indicated that there is still limited information about these substances, including their effect on users, but he did advise that there is a known link in both the literature and in cases the ChemCentre has been involved with, of synthetic cannabinoids leading to hospital admissions and deaths. In New Zealand, 70 deaths were recorded between mid-2017 and mid-2019 relating to synthetic cannabinoids. The adverse effects may be related to user tolerance, differential dosing or underlying health issues, rather than just simple drug exposure, but the numbers still demonstrate the inherent dangers of these types of illicit drugs, particularly given there is no way to know what the person is consuming given the unregulated nature of the product.69
Professor Joyce was able to provide additional information about the dangers of synthetic cannabinoids, particularly as compared to natural 65 Sections 8N – 8U, Part 111B, Misuse of Drugs Act 1981 (WA).
69 T 55 – 56; Exhibit 1, Tab 54.
[2020] WACOR 35 cannabis. He confirmed that we don’t see cardiac deaths from natural cannabis. Further, there are dose limitations on natural cannabis because it is smoked, which prevent people from consuming enough of the drug for it to cause serious toxicity through its effect on the cannabinoid receptor.
In contrast, synthetic cannabinoids have the opportunity of producing effects through the cannabinoid receptors beyond what natural cannabis ever can. In addition, Professor Joyce described synthetic cannabinoids as a “black box in terms of their other toxicology”70 and they quite probably have ‘off target’ effects, but because they have not been studied and tested, we have no idea about what these effects are on humans. Professor Joyce indicated it probably does include effects on cardiac membrane depolarisation. Also, because they are brought into being in illicit laboratories, they are not made through good manufacturing practice, which creates its own risks in terms of what chemicals and antecedent products are in the substances and the degree of purity. Therefore, Professor Joyce concluded there are ample theoretical explanations for these drugs having a range of toxicity which is not shared by natural cannabis.71
Prison Officer Johnson gave evidence he was aware of rumours in the prison before Mr Purnell’s death that Kronic had come into the prison.72 When the police officers investigating Mr Purnell’s death interviewed prisoners who associated with Mr Purnell at the time, many acknowledged they were aware he used Kronic and that it was fairly prevalent in Bunbury Prison at the time. It appears there was a belief amongst prisoners it might be more difficult to detect than some other drugs, which made it more attractive. However, at least one of the prisoners also spoke of their own bad experiences using the drug, which had caused them to avoid using it thereafter. Another prisoner who appeared to have experienced an adverse event using Kronic a few days before Mr Purnell’s collapse said he had been warning other prisoners to stay away from it.73
Following Mr Purnell’s death the prison health services contributed to providing patient education regarding the risks of using Kronic. The Superintendent of Bunbury Prison, Superintendent Kerri Bishop, also addressed all staff and prisoner in Bunbury Prison shortly after Mr Purnell was taken to hospital, to warn of the potential toxicity of synthetic cannabinoids and to warn all prisoners not to consume any such substances and to either dispose of them or hand them in anonymously.74
73 Exhibit 1, Tabs 18 – 31; Exhibit 2, Tab 20.
74 Exhibit 2, Tab 15.
It is unknown how long Mr Purnell had been unresponsive and in cardiorespiratory arrest before he was found. When his cell mate went to sleep Mr Purnell was not in bed, but he was later found in bed by prison officers, so it appears at some stage he got into his bunk before he collapsed. Once the prison officers realised he had stopped breathing, resuscitation attempts were immediately initiated, a medical emergency code was called over the radio and an ambulance was called to attend as a priority, but Mr Purnell had been down too long and had already suffered an irrecoverable brain injury. A defibrillator was applied but found no shockable rhythm. Mr Purnell was taken to hospital and spent a number of days on life support but sadly nothing more could be done for him.
Superintendent Bishop, gave evidence she believed the staff responded to the crisis in a “textbook manner”76 and she believed on review that there was nothing more they could have done to assist Mr Purnell.
Superintendent Bishop emphasised that in these situations, she believes for her staff the notion that the person is a prisoner goes out the window and he becomes a human being in need of urgent attention. She attributed that to a combination of “good training, good culture, good staff.”77 I am satisfied the prison staff did everything they could to try to help Mr Purnell once they realised he had collapsed, but sadly too much time had elapsed without oxygen to his brain, and he could not recover.
Although it would appear Mr Purnell’s pre-existing heart disease played a role in his death, there is no evidence that he had made any complaints of symptoms that might have alerted the prison health staff to the need to initiate further cardiac investigations. This is not unusual, as many people in the community can be walking around not knowing they have heart disease.
I note that Mr Purnell had a long history of illicit drug use, which commenced well before he went into prison to serve this sentence, so there is no suggestion that his incarceration led him to develop a drug habit. Drug and alcohol programmes are available for those who wish to engage with them, and Mr Purnell had been specifically counselled by nursing staff 75 Exhibit 2, Tab 16.
[2020] WACOR 35 against taking non-prescribed medications and other substances and the inherent risks of doing so, but he made the choice to continue to abuse drugs. He was prescribed methadone to try to reduce his urge to do so, but unfortunately this did not curb his desire.
The main issue that arose in this inquest is the ease with which Mr Purnell was able to access an illicit drug in the prison, which raises to some extent the question of supervision.
Evidence was provided by Superintendent Bishop, that Bunbury Prison is the only dedicated re-entry facility in the state were the prison provides services for getting out into the community, which obviously increases the opportunity for illicit substances to enter the prison, even though the prisoners who are allowed outside are vetted and scrutinised closely.78 Since Superintendent Bishop gave evidence she was already implementing strategies at the time of Mr Purnell’s death to try and reduce access to illicit substances and diversion of prescription drugs as much as possible, with a focus on good intelligence, but she also indicated that she was “realistic”79 that these strategies will never be entirely successful. Instead, Superintendent Bishop gave evidence she bases “everything around reducing demand within to reduce the supply in,”80 with a focus on education and management of the individual prisoner.
Further, in a broader sense, the Deputy Commissioner of Adult Male Prisons for the Department, Deputy Commissioner Michael Reynolds, gave evidence of the Officer of the Auditor General’s performance review in 2016 – 201781 to assess whether there was an effective strategy in place to minimise drugs and alcohol in Western Australian prisons. It noted that addressing the presence of drugs and alcohol in the prison system is not an easy or simple task.82 The Department’s efforts were focussed on reducing the amount of drugs and alcohol coming into prisons, as well as efforts to help prisoners with addiction and thereby reduce the demand for illicit drugs and alcohol. The Auditor General emphasised that as long as prisoners desire them, there will continue to be those who attempt to supply drugs, so more needed to be done to treat prisoner’s addictions, as well as preventing the supply of drugs.83
The Department agreed, and in 2018 the Department published the Western Australian Prisons Drug Strategy 2018-2020 to provide a high-level
81 Exhibit 3, Tab 30.
83 T 67; Exhibit 3, Tab 34.
[2020] WACOR 35 blueprint on how the Department is addressing the challenge of drugs in prisons. The key objectives are to:84 eliminate the supply and use of illicit substances in prisons; eliminate the diverted supply and misuse of illicit substances in prisons, increase prisoners’ understanding of drug related harm, increase prisoners’ access to a range of high-quality prevention and treatment services, and reduce the level of risk-taking behaviour associated with illicit drug use by prisoners, with the intention this will reduce drug-related harm for staff, prisoners and the wider community. A specific plan has been put in place in relation to methylamphetamine, given the specific harm and prevalence of that particular drug. The Strategy will apparently be reviewed in 2021.85
At the time of this inquest, the Department was just about to launch the new male Drug and Alcohol Unit in Casuarina Prison, which is a 128 bed unit run by external drug and alcohol rehabilitation providers Palmerston and Wungening Aboriginal Corporation to help break the cycle of addiction and drug-related offending. This demonstrates the commitment of the Department of Justice to reducing the demand from prisoners, as opposed to simply reducing the supply.
Accepting the reality that illicit substances will still find their way into prisons, it is also relevant to consider what might have happened if any prison officers or health staff had realised Mr Purnell was affected by an illicit substance, Officer Johnson confirmed that if a prisoner officer saw a prisoner apparently affected by some kind of substance, they would escort them to the medical centre for their own safety, prior to any other steps being taken from a security and punishment perspective.86 Nurse Clarke confirmed that health staff would then encourage any prisoners to be honest with them about any substances they had taken, with their health being the priority, and would only breach their confidentiality in circumstances where the prison security was likely to be significantly affected because, as she explained, “the boys won’t tell you stuff if they think you’re going to tell somebody.”87 Nevertheless, it was acknowledged that prisoners would generally try to conceal their drug use as they were aware that any drugs 84 T 66; Exhibit 3, Tab 31 and Tab 34.
85 T 69 – 70; Exhibit 3, Tab 34.
[2020] WACOR 35 found would be seized by prison staff and there could be consequences, including loss of privileges and even further charges.88
As I indicated at the conclusion of the inquest, I am satisfied the Department of Justice generally, and Bunbury Prison more specifically, has in place comprehensive strategies to try to reduce the supply of, and demand for, illicit substances in prison. However, realistically there will always be some prisoners who will go to great lengths to obtain drugs in prison, no matter what barriers are put in their way. Unfortunately, Mr Purnell appears to have been one such person.
Based on the available evidence, I am satisfied Mr Purnell received a high standard of supervision, treatment and care while being held in Bunbury Prison.89
Mr Purnell had a long history of polysubstance abuse and had overdosed on several occasions in the past. Although he had a complex mental health history, he received regular mental health reviews while in custody and there is no evidence Mr Purnell had any intention to self-harm during his last prison admission at any time. Instead, his primary issue was persistent drug-seeking behaviour. He had admitted to prison health staff that he had been purchasing medications off other prisoners, and had been counselled against it. It appears he also managed to access illicit drugs within the prison by an unknown means, in particular the synthetic cannabinoid Kronic.
On 17 August 2018, while locked in his cell, Mr Purnell smoked Kronic after taking his prescribed methadone and suffered a cardiac event. He was found unresponsive in his bed when his cell was unlocked to take him to participate in a videolink. Prison officers immediately resuscitated him and Mr Purnell was taken by ambulance to hospital, but he was found to have suffered a significant hypoxic brain injury and his death was declared on 20 August 2018.
After his death, a post mortem examination found Mr Purnell had undiagnosed cardiovascular disease. He had not complained of symptoms suggestive of heart disease to medical staff before his death so no investigations had been undertaken. Although he did not know it, Mr Purnell’s heart disease made using synthetic cannabis even more dangerous than it is for an ordinary person, as the stimulant effect resulted
89 Exhibit 1, Tab 7A.
[2020] WACOR 35 in a cardiorespiratory arrest. After using synthetic cannabinoids on this occasion, he suffered a sudden cardiac event, which caused his death.
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