Finding into death of Person E

70y · Male·organising diffuse alveolar damage in the setting of hypertensive heart disease, right ventricular hypertrophy, coronary artery atherosclerotic stenosis, and chronic obstructive pulmonary disease

A 70-year-old man died in prison custody from organising diffuse alveolar damage in the setting of pre-existing hypertensive heart disease, right ventricular hypertrophy, coronary artery atherosclerosis, and COPD. He presented on 18 April 2023 with acute respiratory symptoms including dyspnoea, dizziness, and epistaxis after losing his regular inhaler. Initial presentation to East Grampians Health Service resulted in same-day discharge, but he rapidly deteriorated requiring transfer to Ballarat Base Hospital where he was admitted with infective COPD exacerbation, later requiring ICU admission. Despite broad-spectrum antibiotics, steroids, and respiratory support, he continued to decline and died 23 days later on comfort care. The coroner found his custodial healthcare was reasonable and appropriate, and the death was not preventable. Autopsy revealed severe organising DAD affecting all lung lobes with no specific identifiable aetiology.