The Queensland Coroner has called for better information sharing between correctional authorities and Queensland Health after the death of a Mornington Island man in jail.
Ashley Glenfield Gavenor, aged 48, died at Townsville Correctional Centre on September 19, 2017 and his death was investigated by state coroner Terry Ryan.
Mr Gavenor died when he collapsed soon after a brief physical altercation with another prisoner.
Though he suffered only minor injuries in the altercation he died from coronary atherosclerosis and minor trauma.
Mr Gavenor suffered from a number of pre-conditions including artery disease, hypertension and diabetes but had refused to take prescribed medication in the months before his death due to cultural beliefs and adverse side effects.
Previously a model prisoner, his refusal to take medication led to a pattern of unusual behaviour which included chanting and removing his clothes.
In the weeks before his death, correctional facility management considered Mr Gavenor's health including involuntary treatment.
Coroner Ryan said this may be needed "where the refusal poses an immediate risk to the prisoner or other persons" but agreed with doctors that Mr Gavenor's treatment was appropriate.
The Coroner also accepted Queensland Correctional Service could not have predicted the fight on the day of his death as it was with a fellow Indigenous prisoner who was a friend of many years, and he also said that prisoner was not to blame for Mr Gavenor's death.
The QCS's own report into Mr Gavenor's death found there was a lack of shared health information with officers unaware of Mr Gavenor's untreated cardiac issues.
The Coroner noted that the Memorandum of Understanding between QCS and Queensland Health was under review at a state-wide level while on a local level Townsville Correctional Centre was meeting with the Nurse Unit Manager to look to share prisoner health information with operational managers.
He also noted all supervisors were told of the importance of briefing their teams on specific prisoner health risks and noted health information should be shared between Queensland Health and QCS with prisoner consent.
"There may be circumstances where the safety of the prisoner or other persons require that information to be shared without consent," Coronor Ryan said.
"(But) it appears unlikely such measures would have changed Mr Gavenor's outcome given he suffered an unforeseeable acute cardiac event."
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