Coronial
QLDother

Gavenor, Ashley Glenfield

Deceased

Ashley Glenfield Gavenor

Demographics

48y, male

Date of death

2017-09-19

Finding date

2019-11-21

Cause of death

Coronary atherosclerosis and minor trauma

AI-generated summary

Ashley Glenfield Gavenor, a 48-year-old Indigenous man with coronary artery disease, hypertension, diabetes, and bipolar affective disorder, died in Townsville Correctional Centre following a brief altercation with another prisoner. He had refused medications for several months citing cultural beliefs. Medical staff appropriately counselled him on risks; a multidisciplinary team assessed him and determined involuntary treatment was not initially warranted. He collapsed suddenly after a physical confrontation, consistent with acute cardiac event given severe coronary atherosclerosis found at autopsy. Resuscitation efforts were prompt and compliant with policy. The coroner found medical care appropriate, responses adequate, and the cardiac event unforeseeable. Key lessons include: complex information-sharing between correctional and health services requires careful consent considerations; prisoners refusing life-threatening medication require documented capacity assessments; and multidisciplinary approaches to mental health in custody should be clearly communicated to custodial staff.

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

Specialties

cardiologypsychiatryemergency medicinegeneral medicinecorrectional health

Drugs involved

aspirinatenololatorvastatinmetforminolanzapine

Clinical conditions

coronary artery diseaseacute cardiac eventsudden cardiac arrestcoronary atherosclerosishypertensiontype 2 diabetes mellitushyperlipidaemiabipolar affective disorder

Procedures

cardiopulmonary resuscitationbag ventilationdefibrillationendotracheal intubationintravenous accesspost-mortem examination

Contributing factors

  • Severe coronary artery stenosis with atherosclerosis
  • Hypertension
  • Diabetes mellitus type 2
  • High cholesterol
  • Non-compliance with cardiac medications
  • Physical altercation/minor trauma
  • Obesity
  • Bipolar affective disorder relapse
  • Medication refusal on cultural/spiritual grounds

Coroner's recommendations

  1. Information sharing with Queensland Health: QCS and TCC management should consider whether information sharing processes between QH and QCS (at State and Local level), including the current MOU, are such that correctional staff are provided with or able to obtain information about prisoners' medical conditions as is legally permissible to ensure staff are informed of potential risks.
  2. Information sharing with Queensland Health (2): TCC management should review whether systems and processes by which information gleaned by supervisors in multi-disciplinary meetings, suggesting particular prisoners are at risk of aberrant or erratic behaviour because of untreated mental health conditions, is appropriately documented, recorded and shared with officers responsible for custodial management.
  3. Prisoners who refuse medications: QCS and TCC management should consider what further action can and should be taken when prisoners with known life-threatening conditions, such as cardiac disease, refuse to take medication, making deaths in custody more likely, with due reference to persons' right to refuse treatment and limitations on circumstances where medication can be required.
  4. Case noting: TCC management should reiterate requirements of the Case Noting/Case Reporting Directive regarding when notes are required to be entered.
  5. Cultural issues: Given the high proportion of Aboriginal and Torres Strait Islander prisoners at TCC, the centre should develop and implement centre-specific strategies for cultural responsiveness and cultural safety in the management of prisoners.
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