Inquest into the death of Benjamin Cullen
Deceased
Benjamin Nathan Cullen
Demographics
41y, male
Date of death
2021-02-25
Finding date
2025-12-08
Cause of death
acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus caused by a tumour abutting the cerebral aqueduct
AI-generated summary
Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from Parklea Correctional Centre, ultimately resulting in hypoxic brain injury and death. Critical failures in release planning contributed to this preventable death: Benjamin was not provided his prescribed levetiracetam (Keppra) antiepileptic medication upon release despite having subtherapeutic levels due to missed doses in custody. Medical evidence established that subtherapeutic Keppra levels most likely precipitated the seizures that fatally elevated his intracranial pressure. Both St Vincent's Correctional Health and MTC Broadspectrum failed to implement required discharge procedures ensuring medication continuity. Systemic failures included inadequate medication administration documentation in custody, failure to provide discharge medication, and inadequate release planning protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- subtherapeutic levetiracetam (Keppra) levels in blood plasma
- missed doses of Keppra during incarceration (7 February and 12 February 2021)
- failure to provide medication at release from custody
- inadequate release planning by correctional and health services
- failure to document medication administration
- inadequate communication between St Vincent's Correctional Health and MTC Broadspectrum regarding discharge medication
- obstructive sleep apnoea
- acute alcohol consumption
- cannabis consumption
- seizures triggered by subtherapeutic Keppra levels
Coroner's recommendations
- That St Vincent's Correctional Health, in consultation with MTC, the Justice Health, and Forensic Mental Health Network and Corrective Services New South Wales, explore options for real time documentation of medication, administration, and or supply in the electronic medication administration record
- That MTC Broadspectrum, in consultation with St Vincent's Correctional Health, review its processes at discharge, including the terms of the discharge checklist completed with inmates shortly prior to their release from custody to ensure its discharge processes are compliant with Corrective Services New South Wales's policies and procedures, including but not limited to COPP 23.2
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