Inquest Reveals Corrections Failures After First Nations Man Denied Request To Die On Country

A coronial inquest has found that a First Nations man, who died in a Sydney hospital three months after being diagnosed with pancreatic cancer, was not properly informed about the severity of his illness and was denied the opportunity to return to Country before his death. 

The inquest, led by Deputy State Coroner Rebecca Hosking, found serious communication failures by Justice Health during the three-day hearing held in Gunnedah in March.

The 53-year-old Gamilaroi man died in hospital after he was diagnosed with pancreatic cancer in mid-2022. Almost three years after his death, the inquest found that the severity of the man’s pancreatic cancer diagnosis was never properly explained to him or his family. 

According to the Agency for Clinical Innovation, Justice Health and Forensic Mental Health Network provides palliative care support to patients referred from across New South Wales. However, inpatient end-of-life care is only available at Long Bay Hospital, located within the Long Bay Correctional Complex, or through transfer to an NSW Health facility. This means inmates in other correctional centres must be transferred to one of these two settings to receive inpatient palliative care. 

The Coroner’s Court of NSW provided the coronial inquest findings to City Hub. 

Inquest Confirms Inadequate Medical Care to Gamilaroi Man 

The cause of death was identified as metastatic pancreatic carcinoma, and the manner of death was determined to be natural causes. The inquest confirmed that the 53-year-old Gamilaroi man passed away while in the custody of Corrective Services NSW (CCNSW).

Several issues were identified during the investigation, which included whether his health was monitored and treated in line with applicable standards and policies during his time in custody between February 2021 and October 2022. Additionally, the adequacy of communication with his family following his diagnosis in September 2022, and whether any recommendations are necessary or desirable regarding matters related to his death.

The inquest also highlighted several inadequacies in his medical care. Justice Health NSW (JHNSW) failed to review his July 2022 blood work in a timely manner, contrary to their own policies, which required the results to be reviewed by 26 July 2022. 

This failure to inform him about his July blood work contributed to him declining an abdominal ultrasound, as the procedure would have required a transfer from Kempsey Correctional Centre (KCC) shortly after he had returned from COVID-19 isolation.

“The care was inadequate, and the doctors failed to review the test results in a timely matter,” Magistrate Hosking said, as reported by ABC News. 

Inadequacies in Corrective NSW’s Management of End-of-Life Care

The inquest also identified shortcomings in Corrective Services NSW’s management of the man’s end-of-life care.

The inmate’s daughter attempted to make arrangements to visit her father at Long Bay Hospital but was unable to reach the ‘Department of Community Justice, Manager of Securities’ as the provided contact number was not operational. 

She later received a phone call from her father, who was under guard at Prince of Wales Hospital. During the call, she described her father as unwell and delirious, with guards laughing in the background. She felt that the guards were mocking her father, calling the experience “dehumanising.” Additionally, she encountered difficulties obtaining information from medical staff due to unclear records, which made it uncertain who was listed as her father’s next of kin.

Inquest Criticises Failure to Consult Inmate and Family Before Transfer Back to Prison

Deputy State Coroner Rebecca Hosking extended her condolences to the man’s four children, who attended the proceedings via audio-visual link. She ruled that the man had not received adequate care while under the supervision of Justice Health.

“Consultation with an inmate and their family after a diagnosis should be done before being transferred back to the prison”, Magistrate Hosking said. 

Inquest Recommends Improved Consultation and Consent Process for Inmates with Advanced Cancer

The inquest made several recommendations to Justice Health NSW (JHNSW), including the consideration of implementing a requirement for clinicians to consult with inmates promptly after they receive an advanced cancer diagnosis or begin palliative care. 

This consultation would determine if the inmate wished to provide consent for JHNSW to liaise with their next of kin regarding their health status. 

The recommendation further states that this process should be completed before the inmate’s transfer to Long Bay Hospital; if not done prior to transfer, it must be actioned upon reception at the hospital.