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'I just want answers': Mr Yeeda's death in custody and the health warnings that failed to save him

The last time Marlene Carlton heard her son’s voice, he was singing to his little brother on their shared birthday. Two days later he was dead.

“We was just all expecting him home,” Carlton says. “He came home but not the way we wanted him to.”

Mr Yeeda, whose first name is not used for cultural reasons, died at Derby regional hospital on 3 May after having a heart attack in West Kimberley regional prison. He was 19.

He was overdue for heart valve replacement surgery before being jailed in April 2017. The Miriuwung and Gajerrong man had rheumatic heart disease, a preventable condition that affects 400 people in the Kimberley and about 6,000 Aboriginal and Torres Strait Islander people across Australia.

Before he was jailed he received regular treatment in the form of monthly Bicillin L-A injections, which is a form of long-acting antibiotic. He had heart surgery at the age of eight to put in the valves, which were due to be replaced.

Carlton says the Ord Valley Aboriginal Medical Service, which managed his treatment in his home town of Kununurra, had sent at least two letters to the Western Australian prison service notifying them that her son was overdue for a heart operation.

147 Indigenous deaths in custody investigated as part of Deaths Inside

Guardian Australia understands Yeeda’s cardiologist also contacted the prison service.

But Carlton does not know whether the prison received the letters, whether her son was seen by a cardiologist while in prison, or even whether he had been listed as requiring a cardiology appointment.

She does not know what medication was in his system when he died because she has yet to receive an interim autopsy report from the coroner.

Yeeda was moved five times between his 18th and 19th birthdays, from Banksia Hill youth detention centre to Acacia prison in Perth, to Albany regional prison, to Greenough regional prison and finally to West Kimberley regional prison in Derby. It is nine and a half hours’ drive from Derby to Kununurra.

Ord Valley Aboriginal Medical Service sent letters to Banksia Hill and Greenough, and Guardian Australia understands it tried to follow up through other avenues.

“I don’t think the letter even reached the prison,” Carlton says.

Mr Yeeda

Mr Yeeda had rheumatic heart disease and was overdue for heart valve replacement surgery before being jailed in April 2017

Her requests for information have gone unanswered. Deaths in custody in Australia are subject to a mandatory coronial inquest and the Department of Justice, which manages corrective services, said it could not provide more information while the coronial investigation was under way.

According to an analysis of Indigenous deaths in custody by Guardian Australia, families in WA wait an average of two and a half years for an inquest to be held, and a further three months for the coroner to deliver the findings.

“It’s been five months already,” Carlton says. “I got his death certificate but not the actual report from the coroner, just a one-page statement saying ‘cardiac arrest’. I just want to know what was in his blood, what sort of tablets he was on … I don’t care how long it takes, I just want answers.”

Yeeda turned 18 a week after he was convicted and given a 16-month sentence, meaning his medication could be changed without Carlton’s consent or knowledge. She knows he was required to take four tablets every day but does not know what they were for or if his monthly injections had been replaced by oral antibiotics.

“All he said was, ‘Yes mum, I am having my medicine,’” she says. “Because he was 18, 19, they are not notifying me.

“Even if he was 29, 30, they still should have notified me. That’s my son.”

The Department of Justice told Guardian Australia it was “not possible or appropriate” to comment on individual cases but added: “Healthcare decisions are made in consultation with adult prisoners and health information is not shared with next of kin unless the patient requests this in writing, or the next of kin requests the information and the patient has provided written consent.”

Monthly Bicillin injections are the recommended treatment for people susceptible to rheumatic heart disease, says Dr Rosemary Wyber from the Telethon Kids Institute.

“There are tablets available but they are less effective,” Wyber said.

The cardiothoracic surgeon Dr Nikki Stamp says while patients may not be willing to keep up the “quite painful” and arduous routine of one injection every 28 days for 10 years, “studies have shown that intramuscular injections to be a superior treatment to tablets”.

The condition is caused by a streptococcus A infection, which can develop into rheumatic fever that, if untreated, can cause scarring on the heart valves. It has been wiped out in most developed countries and is connected to overcrowded housing, poor hygiene infrastructure and poor access to health services.

“This is really a disease of socioeconomic inequality, which is easily preventable,” Wyber said.

Medical issues, often exacerbated by poor communication between different prison health services, were behind 48% of the 147 Indigenous deaths in custody investigated for Guardian Australia’s Deaths Inside project.

Wyber says rheumatic heart disease is managed “erratically” in the WA prison system. Communication both between prisons, and between the prison health service and community health services, is often lacking.

The department says healthcare in WA prisons is provided in accordance with national prison and medical guidelines.

“The Department of Justice strives to provide every prisoner access to health services delivered by registered health professionals at a standard comparable to what is available in the general community,” a spokeswoman says.

Carlton says her son talked excitedly about getting a job as a stationhand once he was released from prison, and spending more time with brothers and sisters. He worried that his baby brother, Kade, who turned two on the birthday they shared, would have forgotten him already.

“We go to the cemetery every day now, and every time we go there we just break down like it was yesterday,” she says. “We talk about him all the time. I just want people to remember him.”

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