A Corruption and Crime Commission investigation has been unable to substantiate claims a senior staff member at Rockingham General Hospital tried to coerce a registrar into changing the date on a patient's death certificate.
The allegations relate to Kevin Reid, who died in palliative care at the hospital in September 2022.
Media reports at the time questioned whether Mr Reid was still alive when he was placed in a body bag and taken to the hospital's morgue.
After those reports, South Metropolitan Health Service chief executive, Paul Forden, denied that was the case and said the only issue was that Mr Reid's death was not formally certified on the night he passed away.
A nursing staff note indicated Mr Reid had passed away at 9:20pm on September 5, and that his family would come in a short time later.
The CCC found that while normally at that stage a doctor would determine "life extinct", that was not done.
Initial query over whether patient was alive at mortuary arrival
A resident medical officer recorded that she had certified another patient's death on a different ward and had been asked to also certify Mr Reid's death.
That doctor told nurses she still had to complete the other patient's paperwork and asked them to contact another doctor for Mr Reid, but that did not occur.
Instead, the registrar was asked to certify Mr Reid's death the following day, after he had been taken to the hospital's mortuary.
"Upon opening the body bag, he observed Mr Reid's left arm up over his right shoulder, his eyes were open and he had a blood clot from an apparent new skin tear on his right arm," the report stated.
"After leaving the mortuary, the registrar discussed his observations with the palliative care team and a member of the [Rockingham Peel Group] executive.
"He was concerned his findings were inconsistent with a person who was deceased on arrival at the mortuary," the report said.
Recorded date of death change 'suggested'
The CCC found that after discussing that possibility, and other possible explanations, it was agreed those observations "did not alter the cause of death and he [the registrar] would complete the paperwork with the time that he reviewed the body as the time he certified death".
As such, the date recorded on Mr Reid's death certificate was September 6.
In his evidence to the commission, the registrar said that a few weeks after Mr Reid died, a ward clerk told him the man's funeral home had enquired about changing the date of death.
The registrar said he was then contacted three times by a senior doctor about Mr Reid's passing.
He said the first time, in the hospital's emergency department, the senior doctor "made a suggestion, rather than a directive" about changing the date, which the registrar declined "as it was not when he had certified death".
The second time, later that day, the senior doctor called the registrar.
"According to the registrar, the senior doctor said he had spoken to the nurse coordinator, on shift on the relevant night, who had assured him she had confirmed Mr Reid was deceased before he was taken to the mortuary," the report said.
"The registrar said he still would not change the date because there was no written record of the nurse coordinator's assessment.
"The registrar's evidence was again there was no direction from the senior doctor to change the date and the senior doctor accepted his response."
The third time came in a phone call the registrar received while at home after a busy night shift.
The senior doctor told the CCC the call was purely to check on the registrar's welfare, and that there was no discussion about the death certificate.
"The registrar had the impression from the call that the senior doctor wanted the date of death changed," the commission found.
"Whether or not he was correct in his impression, he did not change the date of death.
"Appropriately, given his concerns, he sought advice and notified the coroner."
Mix up likely a 'miscommunication'
Corruption Commissioner John McKechnie told ABC Radio Perth the situation was likely a miscommunication.
"[The registrar] thought he was being intimidated and he didn't give into any intimidation, but in fact what we found was the senior doctor was entitled to ask him, and he was entitled to decline," he said.
"It was as much a miscommunication as I think anything else. It's very difficult when you're a young doctor and senior doctors are asking you to do things you may not feel comfortable with."
Mr McKechnie said any suspicions surrounding Mr Reid's death were not of much relevance to the CCC investigation.
He said while "there may have been some slight signs of life", he had "probably [been] certified dead by a nurse".
"Unfortunately, because she neglected to fill in the records, nobody quite knows. It didn't really alter the cause of death in any way.
"The other odd thing was that the registrar doctor made two sets of notes — one he gave to his boss by leaving it in his boss's drawer and the clinical notes he put on file.
"We made repeated requests and they've gone missing so one can see how it looked suspicious and it was certainly worthwhile our investigating, but in the end, we found no evidence of misconduct.
"We do think the hospital needs to look at its record-keeping though."
No evidence of serious misconduct
The commission found that while junior doctors may find it "stressful or intimidating" to be approached "directly and repeatedly" by a member of the hospital executive, there was no evidence of serious misconduct.
"The evidence does not establish that the senior doctor attempted to coerce the registrar to change the date of death on Mr Reid's death certificate," the report states.
"The senior doctor was entitled to ask the registrar to consider a change of date; the registrar was entitled to decline."
As such, the CCC said it would take no further action, but that its investigation was not to be taken as a finding on how Mr Reid died.
Mr Forden said he welcomed the CCC's finding.
"We take reports of misconduct very seriously and have robust policies, practices and processes to manage any misconduct matters throughout our hospitals," he said in a statement.
The CCC's report did identify a "misconduct risk" because certain handwritten notes made by the registrar around the time he examined Mr Reid could not be found.
"I can also confirm a digital medical record system is currently being implemented at Rockingham General Hospital, which reduces the need for paper records," he said.
