Inquest into the death of Robert Curtis

61y · Male·end stage renal failure, in the context of type 2 diabetes mellitus and chronic liver disease

Robert Curtis, a 61-year-old Aboriginal man with end-stage renal disease, end-stage liver disease, and poorly controlled diabetes, was imprisoned for driving while disqualified on 4 February 2019. He fell in the prison shower that evening, sustaining a head injury. Subsequent hospital admissions revealed severe hypotension and ascites requiring drainage. His clinical condition deteriorated despite dialysis, and discussions focused on palliative care. After a family meeting, he was granted compassionate leave to return to Mutitjulu Aged Care Facility on his country, where he died on 26 March 2019 from end-stage renal failure. The coroner found care, treatment and supervision were appropriate. Clinical lessons include recognising when curative dialysis becomes harmful in patients with end-stage liver disease and hypotension, prioritising patient-centred goals of care discussions, and compassionate early release from custody for terminally ill patients.