Inquest into the death of Benjamin Cullen

41y · Male·acute, severe hydrocephalus contributed to by longstanding chronic hydrocephalus caused by a tumour abutting the cerebral aqueduct

Benjamin Cullen, aged 41, died on 25 February 2021 from acute severe hydrocephalus secondary to a brain tumour abutting the cerebral aqueduct. He suffered three seizures on 23 February 2021, two days after release from Parklea Correctional Centre, ultimately resulting in hypoxic brain injury and death. Critical failures in release planning contributed to this preventable death: Benjamin was not provided his prescribed levetiracetam (Keppra) antiepileptic medication upon release despite having subtherapeutic levels due to missed doses in custody. Medical evidence established that subtherapeutic Keppra levels most likely precipitated the seizures that fatally elevated his intracranial pressure. Both St Vincent's Correctional Health and MTC Broadspectrum failed to implement required discharge procedures ensuring medication continuity. Systemic failures included inadequate medication administration documentation in custody, failure to provide discharge medication, and inadequate release planning protocols.