Coronial
NSWcustody

Inquest into the death of Lathan Brown

Deceased

Lathan Brown

Demographics

28y, male

Coroner

Decision ofDeputy State Coroner Devine

Date of death

2024-01-06

Finding date

2025-08-07

Cause of death

Cardiac arrhythmia

AI-generated summary

Lathan Brown, a 28-year-old Aboriginal man, died of cardiac arrhythmia while in custody at Wellington Correctional Centre on 6 January 2024. He suffered sudden cardiac arrest in his cell; emergency response was appropriate and timely by correctional staff standards, with CPR commenced within 3 minutes and defibrillation deployed at 20 seconds after cell entry. However, the coroner identified systemic failures in family communication during his medical emergency. His father was informed Lathan would be transferred to Dubbo Hospital but Lathan was actually transferred to Orange; the family did not reach him before he died at 11:15pm. The coroner found the death was not preventable given the nature of sudden cardiac arrest, but noted substantially better family liaison could have been achieved with clear policy and a designated senior officer responsible for keeping family informed of condition changes and transfer decisions.

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

Specialties

cardiologyemergency medicineintensive careforensic medicinecorrectional health

Error types

communicationsystem

Clinical conditions

cardiac arrhythmiamitral valve prolapsesudden cardiac deathventricular fibrillation or ventricular tachycardia

Procedures

cardiopulmonary resuscitationdefibrillationemergency medical retrievalintubation and mechanical ventilation

Contributing factors

  • Mitral valve prolapse (identified at autopsy)
  • Failure to provide timely and accurate family liaison during medical emergency
  • Inadequate policy framework for family communication in medical emergencies in custody
  • Incorrect information provided to family regarding hospital transfer destination

Coroner's recommendations

  1. Adoption of procedure requiring at least one incoming and one outgoing officer present in J Block officers' station during handover period between A and C watches to facilitate timely response to urgent knock-up calls
  2. Investigation and implementation of measures to improve audio quality of knock-up calls in monitor room at Wellington Correctional Centre, including restoration of functioning handset and ensuring monitor room staff awareness of available hardware
  3. Amendment of COPP 13.2 to require Governor or OIC to delegate a sufficiently senior correctional officer to liaise with Emergency Contact Person (ECP) in circumstances where death of hospitalised inmate may be imminent
  4. Governor or OIC or delegated officer must provide ECP with contact name and telephone number of medical professional at hospital to enable point of contact for ongoing communication
  5. Governor or OIC or delegated officer to be ongoing point of contact for inmate's ECP including regarding planned transfers
  6. Governor or OIC or delegate must facilitate contact and arrangements between hospital staff and inmate's family
Full text
Official source Archived copy

Related cases from NSW

NSWpolice custody2026-03-20

Inquest into the death of Phillip Walton

48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…

Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…

emergency medicineparamedicinediagnosticcommunicationclozapine
NSW2026-03-06

Inquest into the death of Gregory Merriman

58y · Male·acute myocardial infarction caused by ischaemic heart disease

Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experi…

cardiologygeneral practicediagnosticcommunicationperindopril
NSWmental health2026-02-19

Inquest into the death of Jacob McDonald

51y · Male·combined effects of dilated cardiomyopathy with myocardial fibrosis and prescrip…

Jacob MacDonald, 51, died at the Forensic Hospital from combined effects of dilated cardiomyopathy with myocardial fibrosis and toxic levels of clozapine and aripiprazole. He was an involuntary forensic psychiatric patie…

psychiatrycardiologycommunicationsystemclozapine

Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.