743 results
19y · Male·hanging
A 19-year-old male inmate with schizophrenia died by hanging at Long Bay Correctional Centre. Critical failures in mental health care contributed to preventability: despite initial referral in February 2013, he was never…
62y · Male·fatal cardiac arrhythmia secondary to end-stage ischaemic cardiomyopathy
A 62-year-old prisoner with severe ischaemic heart disease, diabetes, and cardiomyopathy died from a fatal cardiac arrhythmia in hospital. He had extensive cardiac history including pacemaker insertion, coronary stents, …
55y · Male·ruptured dissection of the thoracic aorta
Tien Chung Nguyen, a 55-year-old male prisoner, died from rupture of a thoracic aortic dissection during emergency surgery at Royal Perth Hospital. He presented with chest pain and dyspnoea at Wooroloo Prison on 26 Novem…
43y · Male·Ischaemic heart disease
Farin William Daley, aged 43, died of ischaemic heart disease while in custody at Long Bay Correctional Facility. He had suffered a myocardial infarction at age 28 but failed to disclose this medical history during recep…
42y · Male·Hanging
A 42-year-old male prisoner with a history of alcohol dependence, PTSD, and epilepsy died by intentional hanging in Cessnock Correctional Centre. Mental health assessments on reception and during detention found no suici…
48y · Male·Ischaemic Heart Disease
Victor John Russell, aged 48, died in prison of ischaemic heart disease (90-95% left anterior descending coronary artery narrowing). He had family history of early cardiac disease, prior borderline QTc prolongation on EC…
49y · Male·Complications in Association with Advanced Gastric Malignancy
Roy Charles Gilbert, a 49-year-old prisoner serving an indefinite sentence, was diagnosed with advanced gastric adenocarcinoma in August 2013 after presenting with symptoms of constipation, weight loss, and vomiting. Gas…
55y · Male·Complications of fibrosing alveolitis
John Majinski, a 55-year-old prisoner with severe fibrosing alveolitis, pulmonary hypertension, diabetes, and recurrent infections, died from complications of his lung disease while incarcerated. He received intensive me…
47y · Male·Toxic effects of phosphine gas
Jeremy Harding-Roots died from phosphine gas toxicity after deliberately exposing himself to the pesticide fumigant aluminium phosphide (Fumitoxin) during a siege at his former girlfriend's residence. Key clinical and pr…
29y · Male·Multiple drug toxicity
Shane John Robinson, a 29-year-old prisoner with complex medical conditions including Crohn's disease, pulmonary embolism, anaemia and schizoaffective disorder, died from multiple drug toxicity in prison. He had been pre…
47y · Male·acute renal failure caused by bilateral ureteral obstruction due to metastatic c…
Sean Waygood, an Extreme High Security prisoner, died from acute renal failure caused by metastatic colorectal cancer. He presented with abdominal pain, constipation, and blood per rectum in March 2011 but received subop…
34y · Male·Hanging
A 34-year-old man died by suicide by hanging whilst on remand in a correctional facility. He had disclosed his father's suicide 12 years earlier during initial assessment, but was not identified as self-harm risk. In the…
55y · Male·gastrointestinal haemorrhage due to oesophageal varices due to hepatocellular ca…
Robert McIntosh, a 55-year-old prisoner with undiagnosed cirrhosis of the liver, hepatitis C, and hepatocellular carcinoma, died from gastrointestinal haemorrhage and oesophageal varices. While the coroner found that med…
28y · Male·neck compression due to hanging
Mark Payne, 28, a remand prisoner at Yatala Labour Prison, hanged himself in his cell on 2 June 2011 using a canvas smock. He had made recent threats of self-harm and was placed under camera observation in G Division. Th…
68y · Male·Ischaemic small and large intestine complicating cardiogenic shock in the settin…
Ignac Lecek, 68, with hypertension and gout, collapsed in custody and died of ischaemic bowel complicated by cardiogenic shock in the setting of ischaemic heart disease. He complained of feeling ill on 2 October while in…
26y · Male·Neck compression from hanging
A 26-year-old man died by hanging in his correctional centre cell on 26 October 2011. He had a history of mixed personality disorder, anxiety, opiate dependence and previous suicide attempt (age 13), but was not assessed…
18y · Male·acute neck compression due to hanging
Shane Blunden, aged 18, died by hanging in Yatala Labour Prison on 19 September 2011. He was a remanded prisoner with an extensive history of self-harm, including cutting, swallowing batteries and razors, and a previous …
49y · Male·cardiac hypertrophy (longstanding heart disease) complicated by chronic renal fa…
Raymond McDonald, 49 years old, died in custody at Darwin Correctional Centre from cardiac hypertrophy with underlying chronic renal failure and ventricular arrhythmia. He had presented 16 times with chest pain over 12 m…
53y · Male·metastatic pancreatic cancer
Joseph Mallia, a 53-year-old man incarcerated at Barwon Prison, presented with left flank pain and haematuria in November 2011. A CT scan in January 2012 identified concerning pancreatic duct distension suggesting possib…
50y · Male·myocardial infarction caused by coronary atherosclerosis
Desmond Jambajimba Tilmouth, a 50-year-old Aboriginal man, died of myocardial infarction from severe coronary atherosclerosis complicated by end-stage renal disease and an incarcerated strangulated umbilical hernia. He d…
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