Coronial
NSWother

Inquest into the death of Mootijah Douglas Andrew Shillingsworth

Deceased

Mootijah

Demographics

male

Coroner

Decision ofDeputy State Coroner Baptie

Cause of death

chronic suppurative otitis media with secondary infection

AI-generated summary

An Aboriginal man died from complications of chronic ear disease (chronic suppurative otitis media) with secondary infection. He was incarcerated intermittently and presented to custody with known ear disease, but appropriate management and escalation did not occur. He was resistant to medical intervention, but staff did not adequately advocate for or facilitate necessary treatment. The coroner found the death preventable. Key lessons include: recognising the serious sequelae of untreated ear disease in Indigenous populations; ensuring vulnerable detainees receive appropriate medical assessment and follow-up; and advocating for treatment even when patients are initially reluctant. Better access to ENT services in regional/remote areas and alternatives to short-term custody for vulnerable individuals are needed.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

ENT surgeryemergency medicinegeneral practiceinfectious diseasespsychiatry

Error types

diagnosticcommunicationsystemdelay

Clinical conditions

chronic suppurative otitis mediasecondary infectionmental health disorder

Contributing factors

  • failure to manage chronic ear disease in custody
  • inadequate escalation of care
  • patient resistance to medical intervention not overcome by staff advocacy
  • lack of access to ENT services in regional/remote area
  • vulnerability not adequately addressed
  • concurrent mental health conditions complicating management

Coroner's recommendations

  1. Highlight the serious consequences of ear disease, particularly within Indigenous communities in Australia
  2. Consider providing additional medical services in regional and remote areas
  3. Develop alternatives to full-time custody for vulnerable individuals, particularly those with short sentences or on remand
  4. Improve management protocols for detainees with chronic health conditions and mental health vulnerabilities
Full text

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