Inquest into the Death of Colin Albert WINTER

Contributing factors

• entrenched smoking habit spanning decades
• chronic malnutrition and progressive weight loss
• oesophageal candidiasis
• atrial fibrillation
• ischaemic heart disease with previous coronary artery bypass graft
• valvular heart disease with mitral valve replacement
• abdominal aortic aneurysm requiring multiple interventions
• acute kidney injury
• myelodysplastic syndrome with intermittent thrombocytopenia
• inappropriate hospital discharges while severely unwell
• limited capacity of prison infirmary to manage end-stage COPD

Coroner's recommendations

1. Continue implementation of smoke-free prisons policy to prevent tobacco access regardless of prisoner preference
2. Maintain the reinstatement of the Manager, Sentence Management position to ensure briefing notes for Royal Prerogative of Mercy are prepared for prisoners classified at Stage 3 or Stage 4 terminally ill status
3. Continue close monitoring of the terminally ill prisoner list on TOMS to ensure Stage 3 and Stage 4 classifications trigger timely briefing note preparation to the Minister
4. Maintain post-hospital discharge review process with escalation to Director of Medical Services to establish appropriate discharge and transfer care plans between custodial and hospital services
5. Continue improving communication and coordination between Department of Justice and Department of Health regarding capacity expectations and discharge planning