Deceased
Mootijah
Demographics
male
Coroner
Decision ofDeputy State Coroner Baptie
Cause of death
chronic suppurative otitis media with secondary infection
AI-generated summary
An Aboriginal man died from complications of chronic ear disease (chronic suppurative otitis media) with secondary infection. He was incarcerated intermittently and presented to custody with known ear disease, but appropriate management and escalation did not occur. He was resistant to medical intervention, but staff did not adequately advocate for or facilitate necessary treatment. The coroner found the death preventable. Key lessons include: recognising the serious sequelae of untreated ear disease in Indigenous populations; ensuring vulnerable detainees receive appropriate medical assessment and follow-up; and advocating for treatment even when patients are initially reluctant. Better access to ENT services in regional/remote areas and alternatives to short-term custody for vulnerable individuals are needed.
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Specialties
Error types
Conclusion 176 During the course of this inquest, it has become clear that Mootijah's death was preventable. It is accepted that Mootijah was at times reluctant and resistant to medical interventions, both in the community and in custody. It is also clear that Mootijah was a vulnerable individual in both settings. His dual presentations of significant health and mental health conditions was challenging, not the least for Mootijah himself.
177 It is hoped that by investigating his death, the insidiousness and perniciousness of ear disease, particularly within the indigenous communities in Australia has been highlighted. In addition, it is noted that Mootijah was sentenced to short periods of incarceration on a number of occasions. It is unclear whether these periods reflected additional periods of incarceration on remano, or whether they simply reflected sentences of less than six months or possibly breaches of parole. In any event, it is hoped that consideration is given to providing additional services in regional and remote areas to permit the consideration of alternatives to the imposition of periods of full-time custody, where appropriate.
178 I would like to record my gratitude to counsel assisting, Mr Chris McGorey and his instructing solicitor, Mr Gareth Martin, for their assistance, their commitment and their untiring efforts to prepare and present this case.
179 Finally, I would like to again record my most sincere condolences to Mootijah's family. I have annexed the family submissions received from both Mootijah's cousin, Ms and her husband, Mr , to ensure that the proper context and sentiment is recorded appropriately.
180 I close this inquest Magistrate Joan Baptie Deputy State Coroner,
Note: Paragraph 179 of Findings amended 6 October 2022.
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