Inquest into the death of Reuben Button

Contributing factors

• morbid obesity (BMI 43.7) developed in custody
• inadequate weight management despite known risks
• lack of access to dietitian services
• lack of access to Aboriginal Health Worker or Aboriginal Liaison Officer
• infrequent psychiatric consultations (3 visits over 8 months despite complex mental health)
• delays in specialist appointments for sleep apnoea and cardiac investigations
• COVID-19 lockdown restrictions limiting transfers for specialist care
• low oxygen saturation (94%) at time of medication administration
• likely undiagnosed obstructive sleep apnoea
• insufficient clinical curiosity about progressive shortness of breath
• antipsychotic medications causing metabolic side effects and weight gain
• resourcing constraints at correctional centre medical services
• lack of multidisciplinary care coordination

Coroner's recommendations

1. That GEO Group prioritises improvement of the staffing ratios of doctors, Aboriginal health workers and nurses to inmates at Junee Correctional Centre to reduce waitlists and to provide culturally appropriate care for the increasing numbers of inmates at the centre
2. That Justice Health and Forensic Mental Health Network should continue its work advocating for a trial for access to Medicare for Aboriginal inmates, liaising with equivalent bodies in other States to coordinate advocacy