Inquest into the Death of Kevin Gregory Quartermaine

36y · Male·Ischaemic Heart Disease and Severe Multifocal Coronary Atherosclerosis in a man with Diabetes Mellitus

Kevin Gregory Quartermaine, a 36-year-old Aboriginal man and sentenced prisoner at Casuarina Prison, died from ischaemic heart disease with severe multifocal coronary atherosclerosis on 17 May 2002. He had extensive coronary artery disease and had been repeatedly advised by cardiologists at Royal Perth Hospital to undergo coronary bypass surgery between 2000 and 2002. He declined surgery multiple times despite being fully informed of the risks and benefits, apparently due to fear of the surgical procedure. Prison medical staff attempted to optimize his medical management with appropriate medication for his cardiac and diabetic conditions, though he demonstrated periods of non-compliance. On the morning of his death, he experienced a massive myocardial infarction while in his prison cell and was rapidly transferred to Fremantle Hospital. He agreed to undergo coronary angiography but suffered a fatal cardiac arrest in the cardiac catheter theatre before the procedure could be completed. The coroner found the supervision, treatment and care provided while in custody to be adequate, and the death to have occurred by natural causes.