Inquest into the death of Daniel Phillips Johnson

33y · Male·acute hydrocephalus following ventricular blockage by a colloid cyst

Daniel Johnson, a 33-year-old Aboriginal man, died of acute hydrocephalus caused by a colloid cyst in the brain while in custody at Darwin Correctional Centre. He had complained of severe, recurring headaches for months before his fatal seizure. The coroner found that while the cause of death was natural and not necessarily negligent, there was a failure to escalate medical response to his complaints. Key failures included: incomplete documentation of headaches in medical records, a breakdown in communication between prison officers and nurses, unavailability of a CT scan despite appropriate indications, and poor integration of information from a separate Panadol register into clinical decision-making. The coroner concluded that if the cyst had been detected via imaging, timely intervention might have saved his life, though survival was not guaranteed.