DARWIN, Australia – An inquest into the death of a 37-year-old Indigenous man in 2022 in Darwin’s maximum security Holtze prison has revealed several failures and “missed opportunities” in the prison’s health facilities.
The deceased, a Maiyali man from a small Northern Territory community, died in palliative care at Royal Darwin Hospital after suffering a heart attack while serving a prison sentence. The tragic death occurred after a series of concerning events in which he received inadequate health care at the prison, according to a coronial inquest.
The inquest heard that the man had been unmedicated for high cholesterol and a high cardiac risk for several months before presenting to the prison clinic with dizziness and dangerously low blood pressure. Despite clear signs of distress, the man was not hospitalized until it was too late, ultimately resulting in his passing.
The man’s nephew, who was also in custody at the time, had informed prison officers about his relative’s declining health, but was dismissively told that his symptoms were side effects of new medication. This critical delay in receiving proper medical attention raised concerns about the communication between prison officers, medical staff, and prisoners with complex health needs, as well as the lack of Aboriginal liaison officers within prisons.
Furthermore, the inquest revealed a series of missed opportunities in the deceased’s health care. From delayed medication for his high cholesterol to a failure to conduct necessary medical scans and call for immediate hospitalization in the face of dangerously low blood pressure, the lack of proper care was evident throughout the process, leading to devastating consequences.
The testimony of expert witnesses highlighted the preventable nature of the man’s death, further underscoring the significant flaws in the medical care provided within the prison. The coroner’s concerns about the lack of Aboriginal interpreters, as well as the decline in the number of Aboriginal Health Practitioners, brought to light broader systemic issues that need to be addressed to prevent such tragedies from occurring in the future. This case serves as a poignant reminder of the critical need to improve communication, access to medical care, and cultural sensitivity within the prison system.