Inquest into the Death of Russell Graham PENNY
Deceased
Russell Graham Penny
Demographics
56y, male
Date of death
2025-05-10
Finding date
2026-03-09
Cause of death
complications of viral hepatitis related advanced-chronic liver disease
AI-generated summary
Russell Graham Penny, 56, a Noongar man, died from advanced liver disease with hepatocellular carcinoma while in prison custody. With chronic hepatitis C from intravenous drug use, Russell had developed cirrhosis and was diagnosed with aggressive multifocal liver cancer while incarcerated. Despite appropriate medical management by prison and hospital teams, two system failures occurred: Russell missed a 5 March 2025 specialist appointment due to a prison transfer that disregarded his documented appointment, and his family were not promptly notified of his April 2025 hospital admission. The coroner found these oversights unlikely to have materially altered his terminal course. Key clinical lessons include integrating appointment alerts into patient transfer systems, ensuring timely family notification in end-of-life care, and recognizing that appropriate specialist care can be delivered within custodial healthcare settings. Russell received compassionate palliative support until his death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- hepatitis C infection
- alcohol misuse
- intravenous drug use
- cirrhosis
- hepatocellular carcinoma
- respiratory syncytial virus infection
- pneumonia
- hepatic encephalopathy
Coroner's recommendations
- Review whether TOMS database processes appropriately highlight urgent upcoming medical appointments when custodial movements officers consider prisoner placements
- Consider implementing a more prominent alert system on TOMS for urgent medical appointments or provide additional staff training to ensure appointments are considered in movement decisions
- Use Russell's case as a training example to emphasise the importance of considering prisoners' medical status and pending external appointments in movement decisions
- Review policies and procedures for family visits to external facilities to ensure clear, straightforward information is readily available and visits are approved without delay, particularly for terminally ill prisoners
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