Finding into death of Michael Garry Suckling

41y · Male·Cardiomegaly in a man with WHO Class III obesity

Michael Suckling, a 41-year-old Aboriginal man, died in prison from cardiomegaly secondary to morbid obesity (BMI 54.5). He gained approximately 117kg during his 3-year incarceration, with rapid initial weight gain from 82kg to 175kg. While obesity itself was not the direct cause, it created conditions predisposing him to fatal cardiac arrhythmia. Clinical care in the days before death was adequate, but systemic failures included: non-optimal weight management despite Michael's stated desire to lose weight; absence of dietitian referral despite repeated requests; lack of culturally appropriate, holistic, multidisciplinary care; fragmentation of services across prisons; failure to apply trauma-informed approaches recommended for Aboriginal prisoners; and poor follow-up after medical episodes. The coroner found multiple opportunities for improvement in prison healthcare delivery, particularly regarding Aboriginal prisoners' access to culturally safe, continuous, equivalent care modelled on Aboriginal Community Controlled Health Organisation standards.