Finding into death of Anthony George Creaton
Deceased
Anthony George Creaton
Demographics
55y, male
Date of death
2022-11-24
Finding date
2025-10-07
Cause of death
Acute myocardial infarction secondary to coronary artery thrombosis due to coronary artery atherosclerosis
AI-generated summary
Anthony Creaton, 55, died of acute myocardial infarction due to coronary artery thrombosis and atherosclerosis in prison custody. He presented with chest pain on 13 November 2022 (twice) and again on 14 November, but nursing staff did not refer him to a medical officer or call an ambulance despite a clear policy requiring medical assessment for chest pain. Instead, the pain was attributed to gastroesophageal reflux and later to COVID-19. He deteriorated and died on 24 November. The coroner found the healthcare response was inconsistent with policy and represented a missed opportunity for cardiac investigation, though underlying comorbidities (diabetes, hypertension, asthma, cardiac hypertrophy, active COVID-19) were significant. The case highlights systemic deficiencies in prison healthcare and the need for adherence to chest pain protocols.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- COVID-19 infection
- cardiac hypertrophy
- coronary artery atherosclerosis
- failure to refer for medical assessment of chest pain
- failure to call ambulance despite policy requirement
- misattribution of chest pain to gastroesophageal reflux and COVID-19 symptoms
- poor diabetes control and non-compliance with health interventions
- needle phobia affecting healthcare engagement
Coroner's recommendations
- The coroner noted that deficiencies in prison healthcare have been the subject of many coronial investigations and emphasized that people in custody have a right to quality healthcare equivalent to community standards. The finding references the Cultural Review of the Adult Custodial Corrections System and notes that the Victorian Government has responded by implementing a public health model for prison health services.
- The coroner identified that CCA's chest pain management policy was not followed and indicated this is a learning opportunity for the newly appointed health provider at Ravenhall.
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 —