Inquest into the death of Kevin BUGMY

57y · Male·Severe coronary artery disease. It is likely that Kevin's use of inhalants in custody, including on about 13 April 2019, contributed to an ischaemic event resulting in a sudden cardiac death.

Kevin Bugmy, a 57-year-old Aboriginal man, died of severe coronary artery disease while in custody at Cessnock Correctional Centre. The coroner found the care received for his chronic inhalant use disorder was grossly inadequate. Clinical lessons include: (1) abnormal ECG results require timely specialist review and follow-up, not rescheduling for 2 years; (2) health alerts must be properly documented and communicated across systems to inform employment suitability; (3) prisoners with known substance use disorders should not be placed in environments enabling access to chemicals; (4) fragmented service provision (health vs. corrections) creates barriers to holistic care; (5) Aboriginal-specific culturally-safe drug and alcohol programs are essential; (6) excessive transfers undermine continuity of care and health engagement. The failure to escalate the June 2018 ECG showing previous myocardial infarction may have delayed diagnosis of life-threatening coronary disease.