Finding into death of Travis Lee Fernandez

35y · Male·Hanging

Travis Lee Fernandez, aged 35, died by hanging in custody at Dhurringile Prison in November 2014. He had sustained bilateral mandibular fractures in January 2014 treated with open reduction and internal fixation (ORIF). By June 2014, imaging revealed delayed/non-union of the left fracture. A critical screw from the surgical plate became loose in October 2014, prompting dental referral. The dentist referred him for an OPG x-ray but no formal referral reached Dhurringile medical staff; the second dental appointment proceeded without the imaging. While causally unrelated to his death, the coroner identified systemic failures: absence of follow-up on specialist appointments, reliance on Port Phillip Prison as mandatory conduit for secondary care (which deterred treatment), failure to provide referral materials to the dentist, and lack of communication between services about the urgent nature of his presentation. The deceased appears to have experienced some jaw discomfort but not documented severe pain proximate to death.