Finding into death of George Samuel Holmes

86y · Male·Cardiovascular disease in a man with subdural haemorrhage (in keeping with a fall)

George Samuel Holmes, an 86-year-old man in Port Phillip Prison for sexual offences, collapsed in his cell on 4 April 2008, found to have an acute on chronic subdural haemorrhage. He had significant past medical history including myocardial infarction, stroke, and atrial fibrillation on Warfarin anticoagulation. He underwent urgent neurosurgical burr hole drainage and initially recovered well but developed respiratory distress on 5 April and suffered a ventricular tachycardic arrest on 7 April at St Vincent's Hospital. The coroner found the cause of death to be cardiovascular disease with subdural haemorrhage, likely from cardiac-induced collapse leading to the fall. No clinical management failures were identified; the coroner found appropriate care throughout. This was a natural death in custody.