Coroner's Finding: GIBSON Anthony Stephen

53y · Male·aspiration pneumonia on a background of oesophageal cancer and ischaemic heart disease

Anthony Stephen Gibson, aged 53, died in hospital from aspiration pneumonia secondary to oesophageal cancer and ischaemic heart disease. He was serving a prison sentence and was shackled to his bed throughout most of his admission. Medical staff expressed concerns about shackling interfering with care and aspiration risk management, requesting he be positioned at 45 degrees to reduce aspiration risk. Despite clinical requests from June 23 onwards, shackles were not fully removed until the morning of his death. A barium swallow test on July 1 caused massive aspiration that precipitated acute deterioration. The coroner found the shackling did not directly contribute to death; the fatal event was aspiration of barium during a legitimate palliative investigation. However, the case reveals communication failures between correctional services and hospital staff, and demonstrates that appropriate restraint review protocols were lacking. The coroner endorsed subsequent policy improvements made by correctional services regarding restraint decision-making and communication.