Coroner's Finding: Freeman, Keith Vivian

71y · Male·end-stage cardiac failure on a background of ischaemic heart disease with dilated cardiomyopathy

Keith Freeman, aged 71, died in custody from end-stage cardiac failure with ischaemic heart disease and dilated cardiomyopathy. He had complex cardiac history including previous CABG, aortic valve replacement, and implanted ICD. During imprisonment, he developed progressive dyspnoea over several months. Despite multiple consultations, chest imaging showing worsening heart failure, and referral to cardiology, there was delay in specialist assessment. He was eventually admitted to Flinders Medical Centre where echocardiography revealed severely reduced ejection fraction (<20%). Following discharge, he rapidly decompensated and died 6 days later. The coroner found medical treatment appropriate, though the case illustrates challenges in managing advanced heart failure in custodial settings and the importance of timely specialist input in deteriorating cardiac patients.