Inquest into the death of James Cunneen

60y · Male·Ischaemic heart disease with a bleeding duodenal ulcer being a significant contributing condition

James Joseph Cunneen, a 60-year-old man with significant medical comorbidities (ischaemic heart disease, diabetes, peripheral arterial disease), died from cardiac arrest due to ischaemic heart disease with a bleeding duodenal ulcer as a significant contributing factor. He died in custody at Parklea Correctional Centre after deteriorating over 8 weeks of grossly inadequate medical care. Key failings included: discontinuation of proton pump inhibitor medication without clinical review; repeated failures to administer prescribed antibiotics (14 occasions in November); lack of medical officer review until day 44 of incarceration despite clear indications for review; failure to escalate critical vital signs (blood pressure 86/63, heart rate 122) on 13 December; and inadequate clinical oversight of a junior doctor responsible for 1150 inmates. The coroner found the delivery of healthcare was 'chaotic' due to severe understaffing, with one GP managing a population that contractually required multiple doctors. Early hospitalisation on multiple occasions could likely have prevented death.