Inquest into the death of Gregory Merriman
Deceased
Gregory Ronald Merriman
Demographics
58y, male
Date of death
2022-12-27
Finding date
2026-03-06
Cause of death
acute myocardial infarction caused by ischaemic heart disease
AI-generated summary
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 experienced a cardiac event approximately 30 minutes after CS gas was deployed during a prison incident. Although he was not involved in the altercation, he was locked in his cell post-incident. Key clinical lessons include: (1) the importance of earlier comprehensive chronic disease screening for Aboriginal inmates, particularly given family history of cardiovascular disease—a planned screening was not completed during his final custody period; (2) inadequate documentation of the discharge summary from his recent hospital admission (which showed ECG changes suggestive of significant coronary disease); and (3) the value of clear post-incident welfare protocols. The coroner found the use of force was lawful and stress from the incident was unlikely to have precipitated the infarction given his pre-existing severe disease. However, systemic improvements in health screening access and timely information transfer between healthcare systems remain necessary.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- advanced coronary artery disease with previous myocardial infarction
- modifiable risk factors: cigarette smoking, hypertension, hyperlipidaemia
- chronic disease screen not completed as per policy during final custody period
- discharge summary from St Vincent's Hospital (6 November 2022) lacked detail on cardiac investigations and ECG results
- inadequate communication of family history of cardiovascular disease to treating clinicians
Coroner's recommendations
- CSNSW to consider amending Custodial Operations Policy and Procedures 13.7 – Use of Force to include further instructions on action to be taken following deployment of chemical munitions, including: (a) identifying inmates affected by gas or otherwise in need of medical attention; (b) contact required with Justice Health staff; (c) first aid and personal decontamination; and (d) decontamination of areas affected by chemical munitions.
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