Inquest into the Death of Lex Gregory MAHER

45y · Male·atherosclerotic heart disease

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.