Inquest into the Death of Bradley James Raymond STINSON

66y · Male·Cardiac arrhythmia in a man with arteriosclerotic cardiovascular disease, pulmonary thromboembolism and metastatic cancer of the pancreas

Bradley Stinson, a 66-year-old prisoner with a long history of heavy smoking and alcohol use, died from cardiac arrhythmia in the setting of arteriosclerotic cardiovascular disease, pulmonary thromboembolism, and metastatic pancreatic cancer. While the coroner found medical care during imprisonment was comprehensive and appropriate, including timely diagnosis and palliative care, significant criticism centred on inappropriate use of restraints during his final hospital admission. Despite being classified as Stage 3 terminally ill with severe mobility issues and no escape risk, Stinson was restrained with leg chains and mechanical restraints during transfer to hospital and remained restrained until 28 January 2022 when doctors intervened. The coroner found this breached Department policy (COPP 12.3) requiring restraint prohibition for terminally ill prisoners unless risk assessment specifically justified them. The failure to consult medical staff and document restraint rationale represented serious policy non-compliance in a dying patient's final days.