Costelloe, Anthony Gayle
Deceased
Anthony Gayle Costelloe
Demographics
37y, male
Date of death
2002-10-25
Finding date
2009-11-26
Cause of death
Posterior myocardial infarction consequent upon right coronary artery thrombosis and coronary atherosclerosis
AI-generated summary
Anthony Costelloe, a 37-year-old Aboriginal prisoner, died from myocardial infarction on 25 October 2002, less than 24 hours after presenting to the prison medical centre with chest pain. A registered nurse assessed him for only 3 minutes, obtained minimal history, and failed to recognise acute coronary syndrome despite risk factors including Aboriginal status, gender, age, and likely family history of heart disease. No ECG was performed despite availability. The coroner found the assessment based on flawed information and inadequate understanding of cardiac presentation. He was discharged without treatment or firm diagnosis. The autopsy revealed severe coronary atherosclerosis with recent thrombosis. The coroner emphasised prisoners deserve healthcare equivalent to the general public and that correct diagnosis would likely have led to hospital transfer and survival. Queensland Health subsequently implemented reforms including improved screening protocols, cultural awareness training, and chest pain management pathways.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Procedures
Contributing factors
- Failure to diagnose acute coronary syndrome
- Inadequate history taking and clinical assessment
- ECG not performed despite availability
- Incomplete information about family history of fatal heart disease
- Inadequate time spent in consultation (3 minutes)
- Lack of understanding of cardiac symptom presentation in high-risk patients
- Insufficient cultural awareness in assessment of Indigenous patient
- No doctor available on day of presentation; only non-emergency appointment made
Coroner's recommendations
- Improved reception screening of new prisoners using open-ended questions to elicit all relevant information, with forms designed to prevent casual 'tick and flick' assessment
- Regular cultural awareness training for all staff to improve communication with Indigenous prisoners
- Reform of chest pain management protocols including enhanced emergency response packs readily available
- Implementation of flow charts or clinical pathways to assist nurses make better informed diagnoses when prisoners present with chest pain
- Chest pain management pathway to be more inclusive and require recognition that chest pain should be treated as an emergency
- Investigation by Offender Health Services of how many prisoners who have died since the Royal Commission into Aboriginal Deaths in Custody recommendations could have been saved had reforms been implemented sooner
Full text
Related cases
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. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. 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 —