Inquest into the death of Josef Lear

80y · Male·metastatic oesophageal cancer

Josef Lear, an 80-year-old prisoner, died of metastatic oesophageal cancer at the Royal Darwin Hospital Hospice on 7 March 2021. He presented with progressive dysphagia, cough, and weight loss in mid-2020, which was appropriately investigated with gastroscopy, biopsy, and imaging confirming stage 4 cancer with hepatic metastases by October 2020. Medical care was found to be excellent, exceeding community standards. However, systemic prison management issues arose during his final illness: delayed removal of restraints and shackles despite frailty (resolved only after legal intervention), restricted family visiting (one visit weekly initially), inappropriate food provision inconsistent with dietary orders, and inadequate supervision during two unwitnessed falls in February 2021 at night. While his cancer was incurable and prognosis poor, the coroner noted institutional inflexibility regarding compassionate leave due to ministerial directives on sex offenders. Corrections has since amended protocols for palliative care planning and family consultation.