Inquest into the death of Martin Leach

67y · Male·Congestive cardiac failure

Martin Leach, a 67-year-old man serving a life sentence, died from congestive cardiac failure with atrial fibrillation and dilated cardiomyopathy. He had consistently refused life-prolonging medical treatments and completed two Advance Personal Plans (APPs) documenting his wishes. A key tension arose between NT Correctional Services' duty of care and his right to refuse treatment under NT health legislation. On 6 February 2024, after ED assessment, Corrections attempted to authorize treatment without consent under the Correctional Services Act, conflicting with health law. NT Health ultimately obtained legal advice supporting respect for his APP. He was inappropriately placed 'At Risk' for health monitoring rather than genuine suicide/self-harm concerns. The finding highlights systemic gaps: no formal information-sharing protocol between health and corrections regarding APPs; no clear directive for first aid response when APPs exist; and lack of appropriate housing/monitoring options for seriously ill prisoners not requiring hospitalization. Clinical lessons include respecting competent refusal, even in custodial settings, and developing clear inter-agency protocols for end-of-life care.