Deceased
Lex Gregory MAHER
Demographics
45y, male
Coroner
Coroner Hartley
Date of death
2022-12-27
Finding date
2025-03-18
Cause of death
atherosclerotic heart disease
AI-generated summary
Lex Gregory Maher, a 45-year-old Aboriginal man imprisoned at Greenough Regional Prison, died of atherosclerotic heart disease while playing basketball. He had abnormal ECGs detected in March and May 2022 and was appropriately referred to cardiology on a semi-urgent basis. However, his initial appointment on 22 July 2022 was unexpectedly rescheduled to 30 September 2022 without clear documentation. Upon release in August 2022, no discharge letter was provided to his GP (GRAMS) emphasising the importance of cardiology follow-up. When he returned to custody in October 2022, a new cardiology referral was made but he died before assessment. Expert opinion suggests that even timely cardiology review may not have prevented his death, as diagnostic pathways and potential surgery would have taken time. Key clinical lessons: ensure discharge summaries are generated for all released prisoners with outstanding specialist referrals, document reasons for appointment rescheduling, and consider enhanced transition-of-care protocols for cardiovascular risk.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
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33y · Male·Complications of out of hospital cardiac arrest in a man with atherosclerotic ca…
A 33-year-old Indigenous man with Type 2 diabetes, hypertension and dyslipidemia collapsed while playing football in a prison in July 2023, sustaining an out-of-hospital cardiac arrest from which he did not recover. Auto…
58y · Male·complications of oesophageal cancer, with terminal palliative care
Stephen Joseph Schipp, a 58-year-old sentenced prisoner, died from complications of oesophageal cancer with terminal palliative care at Bunbury Regional Hospital. He had been diagnosed with oesophageal carcinoma in Janua…
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