Deceased
Wayne John Albert Harris
Demographics
56y, male
Coroner
Coroner Sarah Tyler
Date of death
2024-11-28
Finding date
2026-04-14
Cause of death
Complications of advanced metastatic sigmoid adenocarcinoma in an adult man with terminal palliative care
AI-generated summary
Wayne Harris was a 56-year-old Aboriginal man with advanced metastatic sigmoid adenocarcinoma who died in prison custody from complications of his terminal cancer. He was incarcerated for 11 years for child sex offences. While overall medical management of his cancer was high-standard, transportation issues prevented him from attending chemotherapy appointments consistently due to anxiety and claustrophobia related to prison vehicles. A misunderstanding about his transport needs in July 2023 led to approximately five months of missed chemotherapy between May and October 2023. Although the coroner found care acceptable, expert review acknowledged that prison constraints prevented care equivalent to community standards. Early identification of transport-related barriers and better communication between health and custodial staff could have ensured more consistent treatment, potentially improving quality of life despite the terminal prognosis.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
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Drugs involved
[2026] WACOR 16 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH TYLER, CORONER HEARD : 9 DECEMBER 2025 DELIVERED : 14 APRIL 2026 FILE NO/S : CORC 3637 of 2024
DECEASED : HARRIS, WAYNE JOHN ALBERT Catchwords: Nil Legislation: Nil Counsel Appearing: Sergeant C. Martin assisted the Coroner.
Ms J. Symons (SSO) appeared on behalf of the Department of Justice.
Case(s) referred to in decision(s): Nil
[2026] WACOR 16 Coroners Act 1996 (Section 26(1))
RECORD OF INVESTIGATION INTO DEATH I, Sarah Tyler, Coroner, having investigated the death of Wayne John Albert HARRIS with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, Perth, on 9 December 2025, find that the identity of the deceased person was Wayne John Albert HARRIS and that death occurred on 28 November 2024 at Bethesda Hospital, 25 Queenslea Drive, Claremont, from complications of advanced metastatic sigmoid adenocarcinoma in an adult man with terminal palliative care in the following circumstances:
Wayne John Albert Harris (Wayne)1 was a 56 year old Aboriginal2 man who died at Bethesda Hospital on 28 November 2024 from complications of advanced metastatic sigmoid adenocarcinoma in an adult man with terminal palliative care.
At the time of his death, Wayne was a sentenced prisoner in the custody of the Chief Executive Officer at the Department of Justice (the Department).3
As Wayne was a sentenced prisoner immediately before his death, Wayne was a “person held in care” under the Coroners Act 1996 (WA) (the Act) and his death was a “reportable death”.4 In these circumstances, a coronial investigation is mandatory.5
The Act requires a Coroner who conducts an inquest into the death of a person held in care to comment on the quality of the treatment, supervision and care of the person while in that care.6
I held an inquest into Wayne’s death at Perth on 9 December 2025. The following witnesses gave oral evidence at the inquest: a. Richard Mudford (Review Officer, at the Department); and b. Dr Catherine Gunson (Deputy Director, Medical Services, at the Department).
The documentary evidence at the inquest comprised one volume of the coronial brief, which was tendered by Sergeant assisting as exhibit 1 at the commencement of the inquest.
The inquest primarily focused on the supervision, treatment and care provided to Wayne during his imprisonment. Given the circumstances of 1 The deceased’s family requested that he be referred to as “Wayne” during the inquest and in this finding.
No disrespect is intended to Wayne, or his memory, in so doing.
2 The deceased’s family have confirmed that Wayne identified as an Aboriginal man, but would not always disclose that when dealing with government agencies. This explains why there are occasionally conflicting records available as to whether Wayne did identify as an Aboriginal man.
3 Prisons Act 1981 (WA) s 16.
4 Coroners Act 1996 (WA) s 3.
5 Coroners Act 1996 (WA) s 22(1)(a).
6 Coroners Act 1996 (WA) s 25(3).
[2026] WACOR 16 Wayne’s death, there was a focus on the medical care provided to Wayne, with an emphasis on the care provided to him regarding his bowel cancer.
For reasons outlined further below, I am satisfied that the supervision, treatment, and care provided to Wayne by the Department during his imprisonment was of an appropriate standard.
The evidence raised an issue about Wayne’s transport to medical appointments, and the support offered to him in relation to his anxiety and claustrophobia in connection with the prison transport options available to him.
As a result, I sought further information from solicitors acting for the Department, and from solicitors acting for Ventia, an external company the Department contracts with regarding the transportation of prisoners, in relation to these concerns. I have carefully considered the submissions filed by solicitors acting for the Department, and the additional information provided by Ventia. My consideration of this issue is detailed further below.
WAYNE Background
Wayne was born on 24 June 1968 in Kalgoorlie, Western Australia. He attended high school at Carine Senior High School until Year 10.7
He had been consistently employed throughout his life, as a factory worker, mechanical labourer and delivery driver. He worked as a tyre fitter for many years, and ultimately established his own business as a mobile tyre fitter. Wayne worked for himself as a mobile tyre fitter until his health deteriorated, at which time he commenced receiving the Disability Support Pension. 8, 9
At the time of his death, Wayne was single, and had three children from two previous relationships.
7 Exhibit 1, Tab 9, p 6.
8 Exhibit 1, Tab 9, p 8.
9 Exhibit 1, Tab 12, p 6.
[2026] WACOR 16 Circumstances of imprisonment
On 28 September 2022, Wayne was convicted after trial by jury in the District Court of multiple child sex offences.10 He was remanded into custody at Hakea Prison as a result of his conviction.11
On 15 November 2022, Wayne was sentenced to 11 years imprisonment, backdated to 22 September 2022 with parole eligibility.12 His earliest eligible date for parole was 21 September 2031, but Wayne died many years before that date.
The sentencing Judge was aware of Wayne’s health status, and prognosis, at the time Wayne was sentenced to imprisonment. The sentencing Judge explained: 13 I accept that your time in prison will be difficult for you and will be more onerous than for a prisoner who is in good health and is not facing the health issues and prognosis that you are. I take that and your poor health into account by way of mitigation. However, I have to balance this against the circumstances and the seriousness of your offending and the need for deterrence and to protect the community, particularly vulnerable children.
Wayne’s medical conditions
As outlined above, Wayne was in very poor health when he was first remanded into Hakea Prison in September 2022.
Wayne had been diagnosed with Stage 3 colorectal (bowel) cancer in 2015, while he was in the community. He underwent surgery, and was treated with chemotherapy. However, in 2018 new tumour deposits were identified which established that the cancer had spread to Wayne’s lung.14
In March 2018 Wayne was diagnosed with Stage 4 metastatic colorectal cancer. He was treated with palliative chemotherapy in May 2018, which was then later changed to immunotherapy until mid-2019. Wayne suffered adverse reactions to his treatment, including skin toxicity,15 10 Exhibit 1, Tab 9, p 8.
11 Exhibit 1, Tab 9, p 9.
12 Exhibit 1, Tab 10, p 13.
13 Exhibit 1, Tab 10, p 10.
14 Exhibit 1, Tab 11, p 1.
15 Exhibit 1, Tab 11, p 1.
[2026] WACOR 16 which presented for Wayne as a severe acneiform rash. This caused him a great deal of discomfort,16 and appears to have been a factor in the change to his treatment.
However, Wayne suffered further adverse effects from the immunotherapy and he stopped that treatment due to those adverse effects.17
In about May 2022, Wayne’s cancer had further progressed, and he underwent a three month course of radiotherapy, which finished in July 2022.18 Scans completed in August 2022 showed that Wayne’s cancer had a partial response to the course of palliative radiotherapy he had completed.19
When Wayne was sentenced to his term of imprisonment two months later, it was noted that Wayne’s “life expectancy is significantly reduced as a result of terminal cancer.”20 At the time Wayne was imprisoned, his cancer was described as “incurable”21 and his long term prognosis was known at that time to be “poor”.22 At that time, it was known that any treatment Wayne received would not cure his cancer. Rather, Wayne’s treatment was aimed at trying to improve his quality of life.
On 11 November 2022, Wayne’s treating oncologist wrote a letter in which he expressed the opinion that Wayne’s life expectancy would be in the range of 12 to 24 months, if he continued to receive palliative chemotherapy.23
16 Transcript, p 21.
17 Exhibit 1, Tab 12, p 4.
18 Exhibit 1, Tab 12, p 4.
19 Exhibit 1, Tab 11, p 1.
20 Exhibit 1, Tab 10, p 9.
21 Exhibit 1, Tab 10, p 9.
22 Exhibit 1, Tab 10, p 9.
23 Exhibit 1, Tab 11, p 1.
During the approximately two years Wayne was imprisoned, Wayne was the subject of a security classification review, assessed for inclusion in offender treatment programs, and participated in an individual management plan, which was regularly reviewed. Wayne was described as a “polite and respectful” prisoner who had not been the subject of any prison charges or disciplinary offences. 24
Wayne was subject to random drug tests, and random cell searches, with no issues arising. He sent and received letters, and received 17 social visits from family members and friends during his incarceration.25
Due to his ill-health, Wayne was not employed during his time in prison.
Initial management of medical issues
Upon his incarceration at Hakea Prison, Wayne had an initial health screening with a nurse on 28 September 2022, and was reviewed by a doctor the following day.26
Wayne’s history of metastatic bowel cancer was noted during that assessment. He was taking three regular medications when he entered custody, an anticoagulant medication, an antibiotic to manage his ongoing skin reaction to his cancer treatments, and a medication for reflux symptoms.27
Prison medical staff noted that Wayne had a CT scan that had been booked by his private oncologist at Joondalup Health Campus while he was in the community. The purpose of the scan was to monitor Wayne’s cancer progression.28 The CT scan was re-scheduled to be undertaken at Fiona Stanley Hospital, as that hospital is a publicly funded hospital, given Wayne’s imprisonment. The scan, and blood tests requested by the admitting prison doctor were completed in a timely fashion.29 24 Exhibit 1, Tab 9.5; Exhibit 1, Tab 9.9; Exhibit 1, Tab 9.10; Exhibit 1, Tab 9.11; Exhibit 1, Tab 9.12; Exhibit 1, Tab 9.13.
25 Exhibit 1, Tab 9, p 15.
26 Exhibit 1, Tab 12, p 6.
27 Exhibit 1, Tab 12, p 5.
28 Exhibit 1, Tab 12, p 4.
29 Exhibit 1, Tab 12, p 6.
In November and December 2022, prison medical staff, Wayne’s private oncologist from Joondalup Health Campus, and the Medical Oncology Clinic at Fiona Stanely Hospital all discussed the appropriate management of Wayne’s terminal cancer in light of his term of imprisonment. It was agreed that Wayne’s care would be transferred to the Medical Oncology Clinic at Fiona Stanley Hospital.30
During Wayne’s admission review, it was documented that he had a longstanding history of an anxiety disorder with claustrophobia and panic attacks. Wayne was not medicated for these conditions, and it seems he had previously managed these matters in consultation with his GP in the community.31 Transfer to Acacia Prison
Following a Management and Placement Assessment, it was recommended that Wayne’s security rating be reduced to medium security. As a result, Wayne was transferred from Hakea Prison to Acacia Prison on 27 December 2022.32
During that assessment, it was noted that Wayne’s terminal cancer would not prevent his placement at Acacia Prison.
On 4 January 2023, Wayne was placed on the Terminally Ill register.
Prisoners with a terminal illness33 are managed in accordance with a policy known as COPP 6.2 Prisoners with a Terminal Medical Condition. Once a prisoner is identified as having a terminal illness, a note is made in the terminally ill module of the Total Offender Management Solution (TOMS) computer system the Department uses for prisoner management.
31 Exhibit 1, Tab 12, p 5.
32 Exhibit 1, Tab 9, p 10.
33 One or more conditions that on their own or as a group, significantly increase the likelihood of a prisoner’s death.
[2026] WACOR 16 the potential for sudden death. For Stage 4 prisoners, death is considered imminent.34
On 20 February 2023, further surveillance scans showed that Wayne’s cancer had returned to his right lung. Wayne discussed these results with his treating medial team, and it was planned that Wayne would re-start palliative chemotherapy on a significantly reduced (50%) dose, due to Wayne’s previous skin toxicity as a result of cancer treatment.35
Wayne attended Fiona Stanley Hospital on 27 February 2023 where palliative chemotherapy was re-started.36 By mid-March 2023, Wayne had developed a skin rash following his chemotherapy. This was a similar reaction to Wayne’s response to earlier treatment in the community. He was given a mild steroid ointment to treat his rash, but it is apparent he was in some discomfort as a result of the side effects of his treatment.37
On 13 March 2023, Wayne refused to attend a further medical appointment at Fiona Stanley Hospital for his next dose of chemotherapy, stating that he felt unwell from his previous chemotherapy, and that he wished to postpone his appointment.38 Wayne attended his next chemotherapy appointment on 20 March 2023.39
On 3 April 2023, Wayne again refused to attend a medical appointment at Fiona Stanley Hospital for chemotherapy, because he was feeling unwell from his previous treatment. Wayne was assessed by the prison medical officer, where the side effects of Wayne’s chemotherapy were discussed, and Wayne explained that while his skin rash was less severe than it had been previously, he was feeling unwell. The prison medical officer arranged for a dietician review, with supplemental drinks provided to address weight loss.40 34 Exhibit 1, Tab 12, p 45-46.
35 Exhibit 1, Tab 12, p 6.
36 Exhibit 1, Tab 12, p 23.
37 Exhibit 1, Tab 12, p 23.
38 Exhibit 1, Tab 12, p 40.
39 Exhibit 1, Tab 12, p 40.
40 Exhibit 1, Tab 12, p 23.
On 17 April 2023, Wayne missed a further medical appointment with Fiona Stanley Hospital for chemotherapy because of a competing dental appointment. Wayne asked a prison nurse to re-book his chemotherapy appointment with Fiona Stanley Hospital, which he then attended on 15 May 2023.41
On 29 May 2023, Wayne refused to attend a medical appointment with Fiona Stanley Hospital for his scheduled chemotherapy. Wayne’s reason for not attending was that his back was sore.42 Wayne had a long history of musculoskeletal injuries (back, neck, shoulder and ribs), and it seems he had difficulty tolerating the hard seat standard prison transport vehicle.43
The Health Services Manager at Acacia Prison was informed that Wayne had declined this appointment, and as a result, they issued a medical certificate, which was also documented in TOMS authorising a soft seat secure vehicle to be provided to transport Wayne to his appointments.44
It appears this request was made in the hope that the transport option would alleviate any pain Wayne might have experienced in the hard seat prison transport vehicles generally used. Unfortunately, while the arranged soft seat vehicle appears to have assisted with Wayne’s back pain, he found the transport vehicle to be claustrophobic, and he felt unable to travel in that transport option, declining appointments on multiple occasions due to the transport options available.
Between 29 May 2023 and 1 September 2023, Wayne did not attend any chemotherapy appointments. Wayne also missed medical reviews with his oncologist during this period.
The below table outlines Wayne’s missed appointments during that time period. On each occasion, it appears that Wayne attended reception at Acacia Prison, and declined the appointment to attend Fiona Stanely Hospital.45 41 Exhibit 1, Tab 12, p 40-41.
42 Exhibit 1, Tab 12, p 41.
43 Exhibit 1, Tab 12, p 17.
44 Exhibit 1, Tab 12, p 17.
45 Exhibit 1, Tab 12, p 41.
[2026] WACOR 16 Date Reason for Refusal 19 June 2023 Claustrophobia – asked for a soft seat vehicle.
17 July 2023 Claustrophobia – asked for a soft seat vehicle.
28 July 2023 Claustrophobia – asked for a soft seat vehicle.
4 August 2023 Not booked in a soft seat vehicle.
1 September 2023 Anxious about getting on truck.
The above table indicates that on these five occasions, Wayne refused to attend medical appointments due to his anxiety and claustrophobia, and the requested or agreed transportation option not being provided to him.46
After Wayne refused his appointment on 28 July 2023, the Health Services Manager noted that Wayne wanted to return to a normal vehicle transfer, as the soft seat vehicle made him feel “enclosed”.47 As a result, the Health Services Manager updated TOMS to reflect that Wayne had “no special travel requirements” and that a “standard vehicle” was required.48
Wayne’s refusal of his appointment on 4 August 2023, and his stated expectation that he was booked in a soft seat vehicle, suggests that there was some confusion about what Wayne was actually requesting. I agree with the conclusion of Dr Gunson that it is possible that in July 2023, Wayne was asking for a standard sedan vehicle, not a standard prison transport truck, to facilitate his attendance at hospital appointments.49
After Wayne refused his appointment on 1 September 2023, Wayne was reviewed by a prison nurse practitioner to discuss options to facilitate Wayne’s attendance at his appointments.50
He said he had tried the normal prison transport vehicle, and a soft seat vehicle, but they made him feel too claustrophobic. Wayne was reluctant to take any anxiety medication to try to manage his claustrophobia, but he was confident he would cope with prison transport in a soft seat sedan instead, which is effectively a standard sedan that would be used in the 46 SSO Submissions on behalf of the Department dated 26 February 2026.
47 Exhibit 1, Tab 12, p 17.
48 Exhibit 1, Tab 12, p 17.
49 Exhibit 1, Tab 12, p 18.
50 Exhibit 1, Tab 12, p 17.
[2026] WACOR 16 community. After discussions with the Health Services Manager, a letter and a medical certificate was supplied to Wayne to approve him for sedan transport for all health appointments. TOMS was updated to reflect this outcome.51 52
This change appears to have been effective at addressing Wayne’s concerns, as Wayne attended the majority of his external appointments from that point, other than when he was experiencing severe side-effects from his previous treatments, or was unwell for another reason.53
Wayne attended his appointment with Fiona Stanley Hospital on 13 October 2023. By that time, Wayne had not attended chemotherapy for approximately five months (since May 2023).54 Wayne attended a further appointment with Fiona Stanley Hospital on 3 November 2023, but on 17 November 2023, declined a further appointment. Wayne’s reason for refusing was the need for more time for a rash to heal after his last treatment.55
On 23 November 2023, Wayne had an Individual Management Plan prepared, in relation to his custody and containment, care and wellbeing, rehabilitation, re-integration and reparation. The officer preparing the Individual Management Plan recommended that Wayne remain at Acacia Prison in line with his security rating. Wayne was considered settled at Acacia Prison. He was receiving visits from family and friends, and was considered to show positive prison behaviours.56
On 1 December 2023, Wayne felt well enough to attend a further appointment at Fiona Stanley Hospital, at which time he was told that PET scans from November 2023 had shown his cancer had progressed into his chest.57 In light of Wayne’s terminal medical condition, the heavily reduced (50%) chemotherapy dose Wayne received due to the side effects he experienced following chemotherapy, the approximately five months of missed chemotherapy appointments, and Wayne’s otherwise variable attendance at chemotherapy appointments for other reasons, the progression of Wayne’s cancer was not unexpected.58 51 Exhibit 1, Tab 12, p 17-18.
52 Exhibit 1, Tab 12, p 25.
53 Exhibit 1, Tab 12, p 18.
54 Exhibit 1, Tab 12, p 40-41; SSO Submissions on behalf of the Department dated 26 February 2026.
55 Exhibit 1, Tab 12, p 42.
56 Exhibit 1, Tab 9, p 11.
57 Exhibit 1, Tab 12, p 6.
58 Exhibit 1, Tab 12, p 7.
At that appointment, Wayne’s treating team discussed with him a possible increase in his chemotherapy dose for his next chemotherapy cycle, although this increase would also bring with it the risk of further side effects from the treatment.59
Wayne refused to attend his next chemotherapy appointment on 15 December 2023, as his skin was still angry and painful following his earlier chemotherapy treatment. Wayne’s treating medical team at Fiona Stanley Hospital considered changing Wayne’s treatment from in person treatment to oral therapy instead, and Wayne was encouraged to attend his next appointment.60 I note that any oral therapy that may be able to be provided in prison would be less effective than the treatment Wayne was receiving in hospital.61
Wayne was scheduled to attend Fiona Stanley Hospital on 12 January 2024, but that appointment was cancelled as the wrong prison transport vehicle was made available. The correct transport was made available for his next appointment, and that appointment took place as scheduled on 2 February 2024.62
Throughout April and May 2024, Wayne attended his scheduled appointments and received treatment and monitoring of his progressive cancer as required. However, in June 2024, Wayne tested positive to COVID-19,63 and Wayne declined hospital appointments while he was recovering.64
Wayne missed another appointment on 12 July 2024 with the oncology team at Fiona Stanley Hospital, on the basis of his anxiety.65
Wayne continued to attend appointments with Fiona Stanley Hospital through August 2024, although his anxiety remained poorly controlled, and he experienced episodes of dizziness and back pain. He was not eating much food, and generally feeling unwell. As a result, Wayne was reviewed by the prison medical officer, and prescribed the antidepressant 59 Exhibit 1, Tab 12, p 7; Transcript, p 26.
60 Exhibit 1, Tab 12, p 26.
61 Transcript, p 13.
62 Exhibit 1, Tab 12, p 42.
63 Exhibit 1, Tab 12, p 43.
64 Exhibit 1, Tab 12, p 7.
65 Exhibit 1, Tab 12, p 18.
[2026] WACOR 16 fluoxetine, for the management of his anxiety. He was also provided a nutrition supplement, given he continued losing weight.66
On 26 September 2024, Wayne had an Annual Health Assessment with a prison registered nurse. Wayne was having issues with the muscles in his left arm, and he was referred to physiotherapy.67
At the end of September 2024, Wayne again refused to attend a scheduled appointment with the oncology team at Fiona Stanley Hospital due to his skin rash, and the fact that he didn’t feel up to the attendance.68
On 4 October 2024, Wayne was reviewed by the prison medical officer.
He reported having weakness to his left arm for the past week, and some weakness in his left leg. A facial droop was observed.69 Wayne was transferred to St John of God Public and Private Hospital, Midland (SJOG) for assessment, given these symptoms may have been a sign Wayne had suffered a stroke, or his cancer may have metastasised into his brain.70
While it is possible that the symptoms Wayne described during his Annual Health Assessment on 26 September 2024 were early signs of the condition that ultimately led to Wayne’s hospitalisation, this possibility arises only with the considerable benefit of hindsight. There is no suggestion that the prison registered nurse who performed that assessment should have had raised suspicions at that time, nor should have arranged for any urgent medical review, or hospital transfer, during that assessment.
Wayne was admitted to SJOG, where CT imaging of his brain showed that there were two areas in which cancer cells had spread into Wayne’s brain (metastases in his right frontal lobe).71
The Director of Medical Services for the Department reviewed Wayne’s case, and in light of the metastases, assessed that Wayne was at risk of 66 Exhibit 1, Tab 12, p 28.
67 Exhibit 1, Tab 12, p 28.
68 Exhibit 1, Tab 12, p 44.
69 Exhibit 1, Tab 9, p 12; Exhibit 1, Tab 12, p 28.
70 Exhibit 1, Tab 12, p 29.
71 Exhibit 1, Tab 9, p 5; Exhibit 1, Tab 12, p 29.
[2026] WACOR 16 sudden death. As a result, Wayne was escalated on the Terminally Ill register to Stage 4 (sudden death is imminent)72. However, after Wayne’s condition responded to medication, the Director of Medical Services revisited that decision, and downgraded Wayne to the Terminally Ill register Stage 3 (is likely to die within three months, or has a condition with may increase the potential for sudden death).73 74
A Stage 3 sentenced prisoner may be considered for early release under the Royal Prerogative of Mercy (RPOM). A briefing note is prepared, and after endorsement by the CEO, it is forwarded to the Minister for Corrections.
In Wayne’s case, a briefing note was forwarded to the Minister for Corrections, but the Department did not recommend Wayne’s early release under the RPOM.75 The reasons for this recommendation was the serious nature of Wayne’s offences, that his health status was considered by the sentencing Judge when Wayne was imprisoned, that the wishes of the victim of Wayne’s offending were not known, and that appropriate community supports had not yet been explored.76
Wayne was advised that the neurosurgical team at Fiona Stanley Hospital were willing to perform surgery on the brain metastases, but that there was no guarantee that successful surgery would improve Wayne’s symptoms. Wayne was unsure about his preferred treatment, and after consultation with his family, Wayne ultimately decided that he would undergo further chemotherapy and radiotherapy instead.77 Transfer to Casuarina Prison (Infirmary)
On 16 October 2024, Wayne was discharged from SJOG to Casuarina Prison, once a bed in the Casuarina Infirmary became available.78 He was managed in the Casuarina Infirmary, and was reviewed daily by nursing staff. Wayne was referred to the Metropolitan Palliative Care Consultancy Service (MPaCCS), for discussion of treatment options 72 Exhibit 1, Tab 12, p 46.
73 Exhibit 1, Tab 12, p 45.
74 Exhibit 1, Tab 9, p 5.
75 Exhibit 1, Tab 9, p 5.
76 Exhibit 1, Tab 9, p 6.
77 Exhibit 1, Tab 9, p 6.
78 Exhibit 1, Tab 12, p 7.
[2026] WACOR 16 directed to his comfort, and in the meantime, he attended appointments with Fiona Stanley Hospital for radiotherapy and chemotherapy.
Around that time, Wayne was still considering all of his treatment options, and continued with radiotherapy and chemotherapy while speaking with the neurosurgery team about the prospect of surgery.
On 25 October 2024, after further discussions, Wayne decided he did not wish to receive CPR in the event of cardiac arrest.79 Wayne elected at that time to continue with palliative chemotherapy.80 Wayne explained that he had limited family contact, and he was offered support through Psychological Health Services, which he declined. Wayne was also given information about how to request consideration for release under the RPOM.81
In November 2024, Wayne’s condition again deteriorated. On 7 November 2024, Wayne was experiencing fatigue and nausea, and had experienced two near falls due to his deteriorating condition. An ambulance was called when Wayne started vomiting and appeared increasingly unwell, and he was admitted to Fiona Stanley Hospital.82
Wayne remained in hospital, where discussions regarding his treatment options continued.
During this hospital admission, Wayne’s health continued to deteriorate.
Prison medical staff, and hospital medical staff, discussed whether Wayne should be discharged back to Casuarina Prison, however it became apparent that Wayne’s health needs could not be appropriately managed at the Casuarina Infirmary.83 As a result, arrangements were instead made for Wayne to be discharged to Bethesda Hospital into a palliative care bed.
79 Exhibit 1, Tab 12, p 35.
80 Exhibit 1, Tab 9, p 12.
81 Exhibit 1, Tab 12, p 34.
82 Exhibit 1, Tab 12, p 8.
83 Exhibit 1, Tab 12, p 8.
[2026] WACOR 16 Discharge to Bethesda Hospital
On 20 November 2024, Wayne was admitted to Bethesda Hospital, where he could appropriately receive palliative care, and end his final days in relative comfort.84 On the same date, the Deputy Director of Medical Services reviewed Wayne’s status on the Terminally Ill register, and escalated him to Stage 4 (death is imminent).85
On 23 November 2024, the treating medical team at Bethesda Hospital advised prison staff that Wayne had reached the final stages of his illness. Prison staff contacted Wayne’s family with that update, and Wayne’s family were given security clearance to visit him at Bethesda Hospital before his death.86
On 28 November 2024, shortly after 8:30 am, Wayne stopped breathing.87 Nursing staff conducted an assessment, and confirmed that Wayne was deceased.88
On the recommendation of the forensic pathologist, Dr Inglis, a full internal post mortem examination was not performed. Dr Inglis performed an external post mortem examination and reviewed post mortem CT scans of Wayne’s body. Dr Inglis also reviewed the medical records.
Dr Inglis’ examination showed a chronically ill looking adult man with evidence of medical intervention.
The post mortem CT scans showed large brain metastases, large right lung metastases, right pleural effusion, coronary artery disease, and lesions in the liver.
At the conclusion of the forensic pathologist’s external examinations, Dr Inglis concluded that the cause of Wayne’s death was complications 84 Exhibit 1, Tab 12, p 8.
85 Exhibit 1, Tab 9, p 6.
86 Exhibit 1, Tab 12, p 39.
87 Exhibit 1, Tab 9, p 6.
88 Exhibit 1, Tab 9, p 14.
[2026] WACOR 16 of advanced metastatic sigmoid adenocarcinoma in an adult man with terminal palliative care.
In assessing the quality of the supervision, treatment and care Wayne received whilst he was incarcerated, I have applied the standard of proof set out in the High Court’s decision in the case of Briginshaw v Briginshaw.89 This requires a consideration of the nature and gravity of the conduct when deciding whether a finding adverse in nature has been proven on the balance of probabilities.
I have also been mindful not to insert hindsight bias into my assessment of Wayne’s supervision, treatment and care. Hindsight bias is the tendency, after an event, to assume the event is more predictable or foreseeable than it actually was at the time.90 Performance Assurance and Risk Directorate Review (PAR Review)
Following Wayne’s death, the Department of Justice’s Performance Assurance and Risk (PAR) Directorate completed an independent review of Wayne’s death, to: a. Provide information relating to the custodial management, supervision, and care of the deceased while in custody to assist the Coroner’s investigation; and b. Identify systemic issues and operational risks that may need to be addressed to prevent similar deaths from happening in the future; and to c. Identify policy or procedural opportunities for improvement.91
I note that the PAR Review made the following comments about Wayne’s management whilst he was in custody: 89 (1938) 60 CLR 336, per Dixon J at pp361-362 90 Dillon H and Hadley M, The Australasian Coroner’s Manual (2015), p10 91 Exhibit 1, Tab 9, p 4.
[2026] WACOR 16 The review found that [Wayne’s] custodial management, supervision, and care were in accordance with the Department’s policy and procedures.92
Recorded reasons for [Wayne] rescheduling appointments often related to his level of wellness following chemotherapy treatment. In relation to his refusals to attend appointments, EcHO notes record anxiety and/or claustrophobia associated with his transport to hospital in a prison truck. Approval was granted for [Wayne] to be transferred to external hospital appointments in a soft seat unsecured vehicle thereafter.93 Health Services Summary Review (Health Review)
Dr Gunson performed a review of the health care provided to Wayne while he was in custody (Health Review).
In the Health Review, Dr Gunson made the following comments about Wayne’s clinical care [my emphasis added]: Health Services can confirm that during his time in custody, [Wayne] received regular, timely, compassionate and appropriate health care, for the most part.
When [Wayne] required additional support, this was always provided in a timely manner, and regular follow-ups were always in place. It can be seen in the medical record that the health team caring for [Wayne] was dedicated and thorough and that they strove to deliver excellent care. Health and custodial staff also ensured Wayne was able to attend his mother’s funeral, and facilitated communications and visits from family members during his final illness.
However, there were some delays and interruptions to [Wayne’s] health care, several of which may have been due to a lack of good communication between health and custodial staff. This resulted in deficits in his cancer treatment, due to Wayne’s refusal of some appointments. Some of these refusals were because he was physically unwell, but he missed 5 consecutive appointments due to his difficulties with the transport vehicle 92 Exhibit 1, Tab 9, p 6.
93 Exhibit 1, Tab 9, p 11.
[2026] WACOR 16 (related to claustrophobia and anxiety). Although his prognosis had been given as 1-2 years (with treatment) at the time of his arrival into custody, it may be that had his transport needs been recognised and accommodated in a more timely manner, that consistent treatment may have given him more time and a better quality of life (although this is, of course, speculation). When significant disease progression was first flagged by his treating specialists, this was after he had missed approximately 5 months of treatments, which (as per his Medical Oncologist’s letter of 1st December 2023) may have affected the rate of disease progression. His treatment had already been considered less than optimal due to his reduced-dose chemotherapy regime, after past adverse reactions. Unfortunately, that would have made his regular and consistent attendance for treatment even more important.
[Wayne’s] diagnosis was ultimately terminal even prior to his arrival into custody, and based on estimates from his specialist, it is likely he would still have passed away whilst in custody. However, it must also be recognised that for a person who has limited time left, it would be even more important to ensure his access to treatments that would ensure his final months to years were of the best quality achievable under the circumstances. While there are particular constraints and challenges unique to the custodial setting, nonetheless our mandate must be to provide health care of a standard equivalent to community standards.
In conclusion, while the health care provided by prison health staff to [Wayne] was of a quality equivalent to the standard of care he would have received in the community, the avoidable delays and interruptions to his hospital care would not have occurred had he been living in the community at the time. Therefore, despite prison health staff clearly doing an excellent job with limited resources, his overall care would not be considered to be equivalent to that which he would have received in the community.
Therefore, due to the fact that he was in custody, and his limited transportation options impacted his ability to attend some of his medical appointments, the care that Wayne received while in prison was not commensurate to that which he would have had in the community.94 94 Transcript, p 10.
[2026] WACOR 16 General Quality of Treatment, Supervision and Care
Having carefully assessed the available evidence, and having due regard to the opinion expressed in the PAR Review, and to Dr Gunson’s opinion outlined above, I am satisfied that in general terms, that the medical management of Wayne’s cancer whilst he was incarcerated was of a high standard.
Further, other than the transportation issues that arose in relation to Wayne’s cancer treatment (which I discuss below), the standard of the supervision, treatment and care Wayne was provided while he was incarcerated was of an acceptable standard.
I am satisfied that the Department appropriately facilitated contact between Wayne and his family members and friends following requisite risk assessments, in a manner that allowed Wayne to be supported by his family as he reached the end of his life.95 Further, I am satisfied that the Department ensured Wayne’s next of kin was appropriately notified as Wayne’s medical condition deteriorated, and that appropriate approvals were given by the Department to authorise Wayne’s family to visit him in hospital if they wished.96 I am satisfied that the Department were compassionate and helpful towards Wayne while he was incarcerated, particularly in making arrangements for Wayne to attend his mother’s funeral.
I am also satisfied that the Department carefully and appropriately considered Wayne’s terminally ill status when assessing whether restraints were required before transferring Wayne to hospital. Wayne was accurately identified as a terminally ill prisoner, and he was assessed as not requiring restraint during hospital transfer.97
In light of the above, I acknowledge the work the Department has done in addressing issues that have arisen in previous inquests surrounding restraint of terminally ill prisoners. It is heartening to see that this issue has not arisen in this case.
95 Exhibit 1, Tab 9, p 10.
96 Exhibit 1, Tab 9, p 6; Exhibit 1, Tab 12, p 39.
97 Exhibit 1, Tab 9.15, p 3.
[2026] WACOR 16 Transportation Issue
As explained above, it is clear that Wayne’s attendance at chemotherapy appointments was sporadic, and that on eight occasions during his incarceration, he refused transport to attend his chemotherapy appointments.98
On five of those occasions, Wayne’s refusal to attend chemotherapy appointments appeared to specifically relate to issues with prison transportation.
Dr Gunson made the following comment, in the Health Review:99 Comment: While the dose of treatment would be determined at the discretion of his treating team, it is clear that Wayne’s transport needs were not met and that this caused a 6-month gap in his chemotherapy treatments. Although Wayne’s treatment was not intended to be curative, nonetheless, his treating team would have expected even palliative treatment to delay cancer progression and therefore maintain his quality of life and possibly his life expectancy, for longer than if he went untreated.
Dr Gunson further expressed the following opinion, in the Health Review:100 Comment: It also appears that despite Wayne’s specific travel requirements having been clearly stipulated on his TOMS Medical Status, that for most of his declined transfers he had not been offered the correct transport at all.
Additionally, his transport requirement was changed back to “standard vehicle” in July 2023, but (to the Author at least) it is not clear that Wayne was requesting his transport be changed to a standard vehicle – it is possible that when he stated he would not be claustrophobic in a “normal vehicle” that he meant a standard car or sedan, rather than a prisoner transport vehicle. So it is possible that this change was due to a misinterpretation.
As outlined above, I agree with Dr Gunson’s opinion. I also accept Dr Gunson’s opinion that while the Department could have acted on the transportation issue earlier, Wayne’s attendance at chemotherapy was never going to cure him, although it might have improved his quality of life.101
I acknowledge that the information available in relation to exactly what Wayne was requesting in July 2023 in relation to his preferred transport 98 Exhibit 1, Tab 12; SSO Submissions on behalf of the Department dated 26 February 2026.
99 Vol 1, Tab 12, p 18.
100 Vol 1, Tab 12, p 18.
101 Transcript, p 11.
[2026] WACOR 16 vehicle is unclear, and I am therefore not critical of the Health Services Manager who made the TOMS entry suggesting Wayne had no special travel requirements at that time.
While the misunderstanding was unfortunate, and may have contributed to some of the appointments that Wayne missed in relation to his treatment, it is only with the considerable benefit of hindsight that the misunderstanding becomes clear, and the pattern of Wayne’s refusal to attend appointments becomes apparent.
I am also satisfied that in September 2023, when the pattern of Wayne’s refusals to attend medical appointments was identified, the Department made appropriate arrangements to ensure Wayne was provided a suitable transport vehicle, and Wayne’s sporadic attendance at medical appointments from that date was primarily due to his ill health from the side effects he experienced from his treatment.
In the Health Review, Dr Gunson carefully considered what may be done to prevent similar issues arising in the future. Dr Gunson noted:102 Recommendation: To prevent similar situations recurring in the future, it would be helpful for health staff to log patient refusals in a separate area of the EMR [Electronic Medical Record], such as in the “Memo” field. This would alert the team should a pattern of consistent refusal begin to emerge, to solve the issue in a more timely manner.
I consider this to be a sensible suggestion from the Deputy Director of Medical Services for the Department, and I am confident that as Dr Gunson indicated in her oral evidence, Dr Gunson will consult with her health staff team, to consider the efficacy of this recommendation, or any measures that might prevent similar situations arising in the future.103
On that basis, I consider it unnecessary to make a formal recommendation on this issue.
Accordingly, I acknowledge Dr Gunson’s opinion that Wayne was not afforded care in custody that was commensurate with the standard of 102 Exhibit 1, Tab 12, p 18.
103 Transcript, p 12.
[2026] WACOR 16 care that would be available in the community, due to the issues that arose in relation to his transportation options.
As I have explained above, the transportation issues that arose were unfortunate, and ideally would have been addressed before Wayne missed approximately five months of chemotherapy appointments.
Wayne was a 56 year old Aboriginal man who died at Bethesda Hospital on 28 November 2024. His cause of death was complications of advanced metastatic sigmoid adenocarcinoma in an adult man with terminal palliative care, and I have determined the manner of his death was natural causes.
Wayne had been diagnosed with Stage 4 sigmoid adenocarcinoma many years before his entry into custody. He had been prescribed courses of palliative chemotherapy for his bowel cancer in the community. At the time Wayne was sentenced to imprisonment in 2022, his treating oncologist expressed the opinion that Wayne would pass away within 1 to 2 years if he continued to receive palliative chemotherapy.104
As anticipated, Wayne’s cancer progressed while he was in custody.
This was monitored and appropriately managed, and Wayne was again commenced on chemotherapy. However, Wayne refused to attend multiple oncology appointments for various reasons, including his claustrophobia and anxiety around the prison transport vehicle used to 104 Exhibit 1, Tab 11.
[2026] WACOR 16 take him to hospital for these appointments, and the side effects he experienced from his treatment.
As noted above, and having reviewed the specific issues arising on the evidence, I am satisfied that the supervision, treatment, and care provided to Wayne by the Department during his incarceration was of an acceptable standard.
While it is unfortunate that it took some time for Wayne’s difficulties with prison transportation to be resolved, I am satisfied that appropriate efforts were made by the Department to address the issue once it was recognised, in the hope that Wayne would agree to attend his scheduled appointments and receive appropriate treatment.
In early November 2024, Wayne’s condition deteriorated, and he was taken to Fiona Stanley Hospital. On 14 November 2024, his care was directed to comfort measures. At that time, it was agreed that Wayne required care beyond that which could be offered in the infirmary setting of Casuarina Prison, and Wayne was transferred to Bethesda Hospital, where he was kept comfortable until he passed away on 28 November 2024.
I express to Wayne’s family and loved ones my sincere condolences for their loss.
S Tyler Coroner 14 April 2026
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