An Aboriginal teenager who died in prison from complications due to rheumatic heart disease would not have died if he had seen a specialist, a Western Australian coroner has found.
The 19-year-old Miriuwung and Gajerrong man, referred to by the court at his family’s request as Mr Yeeda, died in May 2018 at the West Kimberley regional prison after suffering severe aortic regurgitation stemming from his condition.
He collapsed shortly after playing basketball.
WA coroner Ros Fogliani said there were missed opportunities to ensure Yeeda received appropriate medical care, including a failure to follow up on a request for an appointment with a specialist cardiologist.
In findings released last month and published this week, Fogliani wrote that if the teenager had undergone aortic valve replacement surgery, “it is likely that his death would have been prevented”.
“Numerous opportunities were missed, when it came to ensuring Mr Yeeda was offered a cardiology appointment … he urgently needed an appointment and it may have saved his life,” she said.
Fogliani recommended the Department of Justice and the WA Country Health Service work together to ensure follow up care, referrals and external appointments are carried out and to set up better tracking systems for referrals. She also recommended the justice department consider making a list for prison officers of any inmates who may have health alerts regarding their fitness for sport or work.
Yeeda had seen a cardiologist on a number of occasions as a child and teenager. He was twice listed for aortic valve replacement surgery, in 2015 and 2016, but the surgery did not proceed due to lack of consent. Fogliani noted that “the fact that there had been no past consent did not mean there would be no future consent”.
Yeeda was jailed in May 2017 and moved to five different prisonsbetween his 18th and 19th birthdays before he arrived at the West Kimberley regional prison in Derby.
He had previously declined advice to be seen by a cardiologist while in custody as he wanted his grandmother to be with him during the consultation to help explain what was happening.
Once in Derby near family he agreed to see a cardiologist but the referral, which he agreed to on 5 December 2017, was not progressed. Despite being marked as urgent there was no follow-up when the referral was not acted on within 30 days.
Yeeda died five months later, having never seen a cardiologist.
Yeeda’s family was represented at inquest by the National Justice Project. Principal solicitor, George Newhouse, said Yeeda’s death was preventable.
“This was a clear failure to provide Mr Yeeda with urgent care and that is a shocking indictment on the system,” Newhouse told Guardian Australia.
“He needed urgent attention and yet he was neglected by the system and left to die.”
Yeeda’s mother, Marlene Carlton, said her son was deeply missed.
Yeeda died six weeks before he was due to be released. He was described by prison staff as being “quiet and gentle” with both prisoners and staff.
“He was looking forward to life,” Carlton said. “He wanted to do his time so he could come out and live with his dad on a station and work with horses.”
She said there was a lack of clear communication about her son’s care and treatment and called for more culturally appropriate healthcare in prisons.
“There should be a better system to monitor their health, and they need people in the prison who understand Indigenous culture and health,” Carlton said.
The Department of Justice has made changes after Yeeda’s death, the coroner’s report noted, including updating its training and advice on prisoners with rheumatic heart disease.
It introduced specific care plans for prisoners with the condition including follow up nursing appointments and referrals.
The department said it acknowledges the coroner’s findings and is reviewing the recommendations.
“All deaths in custody are taken seriously and systems and processes will be reviewed in light of the Coroner’s recommendations,” a spokesperson said.
