West Kimberley Regional Prison inmate Lewis Walter Ward’s death may have been prevented coroner finds

The WA Coroner has found an Aboriginal man who died after suffering a heart attack at West Kimberley Regional Prison in 2023 may have been prevented if he had undergone an exercise stress-test earlier. However, Acting State Coroner Sarah Helen Linton also noted that she could not make a finding that the man’s death could have definitely been prevented. Lewis Walter Ward, who was in his early 30s, died in Royal Perth Hospital on July 25, 2023, after suffering a heart attack while playing football at the prison near Derby on July 15. Despite conducting CPR and using a defibrillator on Ward as soon as possible after his collapse, the inquest noted that by the time he had reached RPH, oxygen deprivation had caused brain death. Mr Ward was due to undergo an exercise stress test in February 2022 but due to miscommunication, Ward missed the appointment. On July 3, 2023, the missed appointment was finally identified with another made for July 18, 2023. However, he collapsed three days before that appointment. “Taking the evidence before me at its highest, I am satisfied there was a missed opportunity to investigate Mr Ward’s cardiovascular health through an exercise stress test, due to the failure by the Department and WACHS to identify the appointment had been missed for a lengthy period,” Coroner Linton said. “Such testing may have identified that Mr Ward required further cardiovascular testing/intervention, but I cannot find conclusively that it would have prevented Mr Ward’s death, given the many unknowns.” Ward was serving a sentence for “a serious act of violence” against his baby daughter when he died. He was sentenced in August 2021 for the “act of violence” which was intended for his partner and was due to be eligible for parole in September 2023. Ward had a history of heart disease and other medical conditions including Type 2 Diabetes and high cholesterol. An echocardiogram (ECG) performed before Ward’s death on September 20, 2022, suggested he had suffered from a heart attack in the past, although Ward may have been unaware it had occurred. Coroner Linton recommended that the Department of Justice consider improving the coverage of CCTV cameras over the football oval at West Kimberley Regional Prison and work towards introducing body worn cameras in all prisons, including at West Kimberley Regional Prison.