Coronial
NThospital

Inquest into the death of Martin Leach

Deceased

Martin Leach

Demographics

67y, male

Date of death

2024-08-03

Finding date

2026-02-10

Cause of death

Congestive cardiac failure

AI-generated summary

Martin Leach, a 67-year-old man serving a life sentence, died from congestive cardiac failure with atrial fibrillation and dilated cardiomyopathy. He had consistently refused life-prolonging medical treatments and completed two Advance Personal Plans (APPs) documenting his wishes. A key tension arose between NT Correctional Services' duty of care and his right to refuse treatment under NT health legislation. On 6 February 2024, after ED assessment, Corrections attempted to authorize treatment without consent under the Correctional Services Act, conflicting with health law. NT Health ultimately obtained legal advice supporting respect for his APP. He was inappropriately placed 'At Risk' for health monitoring rather than genuine suicide/self-harm concerns. The finding highlights systemic gaps: no formal information-sharing protocol between health and corrections regarding APPs; no clear directive for first aid response when APPs exist; and lack of appropriate housing/monitoring options for seriously ill prisoners not requiring hospitalization. Clinical lessons include respecting competent refusal, even in custodial settings, and developing clear inter-agency protocols for end-of-life care.

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

Specialties

emergency medicinecardiologypalliative carecorrectional healthpsychiatry

Error types

systemcommunicationdelay

Drugs involved

morphineparacetamolduloxetinemetoclopramideondansetronapixaban

Clinical conditions

atrial fibrillationcongestive cardiac failuredilated cardiomyopathychronic obstructive pulmonary diseasecardiogenic shock

Contributing factors

  • Atrial fibrillation with rapid ventricular response
  • Dilated cardiomyopathy
  • Chronic obstructive pulmonary disease
  • Long-standing refusal of preventative medical treatment for atrial fibrillation
  • Delayed diagnosis of atrial fibrillation (diagnosed 2023, approximately 15 years after onset of symptoms)

Coroner's recommendations

  1. NT Department of Corrections and NT Department of Health together review, amend and/or develop directives, procedures, training, guidelines, standard operating procedures or similar, and/or progress legislative reform if necessary, that clearly addresses the processes, responsibilities, sharing of information and actions of respective Correctional Services and Health staff when dealing with prisoners who have an Advance Personal Plan or who have made Advance Consent Decisions, with completion and full implementation within 12 months
  2. NT Department of Corrections and NT Department of Health together review, amend and/or develop directives, procedures, training, guidelines, standard operating procedures or similar that clearly address the processes, responsibilities, sharing of information and actions of respective Correctional Services and Health staff when dealing with prisoners who are marked 'At Risk', with completion and full implementation within 12 months
  3. NT Department of Corrections and NT Department of Health together review, amend and/or develop directives, procedures, training, guidelines, standard operating procedures or similar that clearly address the processes, responsibilities, sharing of information and actions of respective Correctional Services and Health staff when dealing with prisoners who are too unwell for 'normal housing' but do not require emergency department care or hospitalisation, with completion and full implementation within 12 months
Full text
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Source and disclaimer

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