Inquest into the Death of Aurelio Monterlegre CRUZ

Contributing factors

• end-stage renal failure
• refusal of dialysis treatment
• uraemic encephalopathy
• hypercalcaemia
• progressive dementia and cerebral atrophy
• chronic obstructive pulmonary disease
• congestive heart failure
• ischaemic heart disease
• multiple comorbidities
• delayed family notification of terminal status

Coroner's recommendations

1. The coroner made a general comment (rather than a formal recommendation) that aspects of how and when family should be contacted in relation to a terminally ill prisoner might be better placed within Policy Directive 8, with more thought given to types of decisions likely to arise with a prisoner suffering from terminal illness.
2. Medical staff within the prison might take more initiative in assisting with identifying the prisoner's wishes and facilitating completion of forms such as 'do not resuscitate' or other health directives, which could then be communicated with consent to nominated next of kin.
3. Where a doctor is making a recommendation for removal of restraints in a prisoner known to have delirium, that clinical information and supporting guidelines should be provided to the relevant decision-maker so they can fully understand when balancing security with prisoner wellbeing.
4. In future cases, the Department should consider alternative means of contact (such as checking visitor registers, flagging on visits, or requesting local police attendance) if simply leaving messages is not achieving contact with family when a prisoner's health has dramatically declined and death may be imminent.
5. The coroner noted it would be appropriate for the Department to think more laterally about alternative contact methods in similar circumstances to ensure families are alerted to imminent death.