Coronial
VICother

Finding into death of Travis Lee Fernandez

Deceased

Travis Lee Fernandez

Demographics

35y, male

Coroner

Deputy State Coroner Paresa Spanos

Date of death

2014-11-23

Finding date

2020-01-15

Cause of death

Hanging

AI-generated summary

Travis Lee Fernandez, aged 35, died by hanging in custody at Dhurringile Prison in November 2014. He had sustained bilateral mandibular fractures in January 2014 treated with open reduction and internal fixation (ORIF). By June 2014, imaging revealed delayed/non-union of the left fracture. A critical screw from the surgical plate became loose in October 2014, prompting dental referral. The dentist referred him for an OPG x-ray but no formal referral reached Dhurringile medical staff; the second dental appointment proceeded without the imaging. While causally unrelated to his death, the coroner identified systemic failures: absence of follow-up on specialist appointments, reliance on Port Phillip Prison as mandatory conduit for secondary care (which deterred treatment), failure to provide referral materials to the dentist, and lack of communication between services about the urgent nature of his presentation. The deceased appears to have experienced some jaw discomfort but not documented severe pain proximate to death.

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

Specialties

oral and maxillofacial surgeryemergency medicinecorrectional healthdentistrypsychiatrygeneral practiceradiology

Error types

communicationsystemdelay

Drugs involved

methadonefluoxetinemirtazapinepregabalinparacetamolcodeineibuprofenescitaloprammethamphetamine

Clinical conditions

mandibular fracturespost-operative surgical site infectiondelayed/non-union of left mandibular fracturedepressionpost-traumatic stress disorderopioid dependencehepatitis Cchronic back painneuropathic paindental caries

Procedures

open reduction and internal fixation of mandibletooth extractionorthopantomogram radiographycomputed tomography imaging

Contributing factors

  • Death in custody at Dhurringile Prison
  • Underlying depression and PTSD symptoms
  • Recent jaw injury with known delayed union and loose hardware
  • Systemic failures in specialist follow-up and communication between healthcare providers
  • Barrier to specialist care via mandatory Port Phillip Prison transfer deterring prisoner from seeking treatment

Coroner's recommendations

  1. Justice Health collaborate with custodial health care providers to collect data on reasons prisoners refuse medical treatment or specialist appointments to inform improvements to custodial healthcare system
  2. Corrections Victoria collaborate with Justice Health and custodial health care providers to establish common approach to 'special circumstances' warranting transfer for secondary and tertiary healthcare other than via Port Phillip Prison, and ensure primary healthcare providers are aware this facility exists and when to recommend it
  3. St Vincent's Correctional Health consult with Justice Health and consider revising policy of removing prisoner patients from outpatient waiting lists after two consecutive appointment cancellations, as information about why appointments were cancelled or by whom does not appear to be meaningfully collated
  4. Rumbalara Aboriginal Co-operative Limited consider revising Medical History Questionnaire to include field, preferably on first page, to capture information relating to previous/recent dental surgery
Full text
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Source and disclaimer

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