Inquest into the Death of Russell Graham PENNY

56y · Male·complications of viral hepatitis related advanced-chronic liver disease

Russell Graham Penny, 56, a Noongar man, died from advanced liver disease with hepatocellular carcinoma while in prison custody. With chronic hepatitis C from intravenous drug use, Russell had developed cirrhosis and was diagnosed with aggressive multifocal liver cancer while incarcerated. Despite appropriate medical management by prison and hospital teams, two system failures occurred: Russell missed a 5 March 2025 specialist appointment due to a prison transfer that disregarded his documented appointment, and his family were not promptly notified of his April 2025 hospital admission. The coroner found these oversights unlikely to have materially altered his terminal course. Key clinical lessons include integrating appointment alerts into patient transfer systems, ensuring timely family notification in end-of-life care, and recognizing that appropriate specialist care can be delivered within custodial healthcare settings. Russell received compassionate palliative support until his death.