Deceased
Gregory Ronald Merriman
Demographics
58y, male
Coroner
Decision ofDeputy State Coroner Grahame
Date of death
2022-12-27
Finding date
2026-03-06
Cause of death
acute myocardial infarction caused by ischaemic heart disease
AI-generated summary
Gregory Merriman, a 58-year-old Aboriginal man, died from acute myocardial infarction caused by advanced ischaemic heart disease while in custody at Metropolitan Reception and Remand Centre on 27 December 2022. He experienced a cardiac event approximately 30 minutes after CS gas was deployed during a prison incident. Although he was not involved in the altercation, he was locked in his cell post-incident. Key clinical lessons include: (1) the importance of earlier comprehensive chronic disease screening for Aboriginal inmates, particularly given family history of cardiovascular disease—a planned screening was not completed during his final custody period; (2) inadequate documentation of the discharge summary from his recent hospital admission (which showed ECG changes suggestive of significant coronary disease); and (3) the value of clear post-incident welfare protocols. The coroner found the use of force was lawful and stress from the incident was unlikely to have precipitated the infarction given his pre-existing severe disease. However, systemic improvements in health screening access and timely information transfer between healthcare systems remain necessary.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Gregory Ronald Merriman Hearing dates: 29 September – 1 October 2025, 3 October 2025 Date of Findings: 6 March 2026 Place of Findings: Coroners Court of New South Wales, Lidcombe Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: CORONIAL LAW – mandatory inquest – death of a First Nations man in custody – use of force event in response to other inmates fighting in a POD – deployment of chemical agent Orthochlorobenzalmalononitrile (CS gas) – was the deployment a reasonably necessary use of force – whether a reasonable and adequate process was undertaken to subsequently check inmates’ welfare – compliance with policies and procedures – appropriateness of cell placement and whether a chronic disease screen should have been performed during final period of custody – recommendation File number: 2022/00391153 Representation: Counsel Assisting the Inquest: J Harris of Counsel i/b Solicitor, Coroners Court Secondment Unit.
Solicitor Advocates for Shannon Merriman, Senior Next of Kin: E Parker & F Al Majed, Aboriginal Legal Service.
Commissioner of Corrective Services NSW: William de Mars of Counsel i/b Department of Communities and Justice Legal.
Chief Executive of the Justice Health and Forensic Mental Health Network: Kate Holcombe of Counsel i/b Hicksons, Hunt & Hunt.
Non publication orders: Non-publication orders made on 30 September 2025 and 6 March 2026.
A copy of the orders can be obtained on application to the Coroners Court of New South Wales registry.
Findings: Identity The person who died was Gregory Ronald Merriman.
Date of death Greg died on 27 December 2022.
Place of death Greg died at the Metropolitan Reception and Remand Centre, Silverwater NSW.
Cause of death Greg died from acute myocardial infarction caused by ischaemic heart disease.
Manner of death Greg died while he was lawfully detained as an inmate in a correctional centre. Following a lawful use of force, where Orthochlorobenzalmalononitrile (CS gas) was deployed against other inmates, Greg was locked inside his cell. He was discovered unresponsive about 30 minutes later. His death was a result of natural causes.
Recommendations: To the Commissioner of Corrective Services NSW (CSNSW):
Circulation of findings A copy of the findings should be provided to the NSW Minister for Health and Minister for Regional Health and the NSW Minister for Aboriginal Affairs and Treaty.
Table of Contents Should Greg have received a Chronic Disease Screen during his final period of Was Greg’s cell placement appropriate during his final period of custody? What factors Whether the deployment of CS spray on 27 December 2022 was a reasonably necessary Was a reasonable and adequate process undertaken to check inmates’ welfare, following
Introduction
This inquest concerns the death of Gregory Ronald Merriman. At the time of his death, Greg was 58 years of age. He was a proud First Nations man of Yuin heritage and a direct descendant of Umbarra (King Merriman). Greg had deep connections to the Gadigal Land and the 29 tribes of the Eora nation where he was raised.
Greg died on 27 December 2022 at the Metropolitan Reception and Remand Centre (MRRC) in Silverwater.
Greg is survived by his daughter, Shannon, his older brother, Mark, his grandchildren and great-grand-daughter, along with many other relatives and friends. Shannon attended the inquest each day, and Mark joined remotely on the final day when his health permitted.
Greg and his siblings were removed from their family under the now-repealed Aborigines Protection Act 1909 (NSW). This legislation empowered the NSW Aborigines Protection Board to remove indigenous children in wide ranging circumstances. Greg, like his siblings, spent much of his childhood navigating the trauma of being taken from his family, being told that he had been neglected, and being placed in boys’ homes and custodial institutions. His family described how the very systems supposedly created to protect him ultimately failed and traumatised him. He experienced great harm in those settings, but he survived them.
Both Greg and his older brother Mark, gave evidence before the Royal Commission into Institutional Responses to Child Sexual Abuse.
Mark observed that although both he and Greg spent time in custody, he had been able to eventually break free from that cycle, while Greg had remained caught in what he described as a “revolving door”, until his passing.
In a CSNSW Case Note dated 13 April 2021, it was recorded that Greg “would often talk about his child hood trauma which he said attributed to his mental health, drug use and his offending… He reported being at peace in his life and wants to put his offending behind him and become a mentor for young indigenous people.”1 0F
Greg’s life was not an easy one, but his family was clear that he was never short of love. Mark described him as a “larrikin” who was preparing to take on a greater role as an Elder prior to his death. His daughter, Shannon said that Greg would “give you the shirt off his back if he could”.
1 BOE, Tab 49, Folio 7(a) (Vol 3) p.1045.
While in custody, he served as the Koori delegate and was clearly well respected. Evidence from GW, a friend and former inmate housed in the same POD at the MRRC as Greg, highlighted that Greg helped anyone and everyone.2 He was regarded as a peacemaker, 1F tutor, mentor and friend. The witnesses who knew Greg painted a consistent picture of a man who was kind, respected and trusted.
Greg held a long-term aspiration of securing a place on the Central Coast with a granny flat where he could live close to Shannon and remain within reach of his family.
Although the inquest necessarily focussed on the events of 27 December 2022, the day of Greg’s passing, and the care and treatment he received during his final period of incarceration, his family shared reflections on the profound meaning he brought to their lives.
I acknowledge and respect the family’s participation in these difficult proceedings. Greg’s family emphasised that there are far too many First Nations people who share similar histories, reflecting the continuing impacts of colonisation, intergenerational trauma and social exclusion on daily life. I share their concerns. His family wished for Greg’s story to be heard and hoped that the system Greg spent his life struggling against might change so that other families do not experience a similar loss. Greg’s family sought clarity regarding the circumstances of his death and expressed a clear desire to contribute to systemic improvements that might prevent future harm. I extend to them my sincere condolences and gratitude for their attendance and contributions to this inquest.
The role of the coroner and the scope of the inquest
The role of the coroner is to make findings as to the identity of the nominated person and in relation to the place and date of their death. The coroner is also required to address issues concerning the manner and cause of the person’s death.3 A coroner may make 2F recommendations, arising from the evidence, in relation to matters that have the capacity to improve public health and safety in the future.4 3F
When a person dies in custody in NSW, it is mandatory that an inquest is held.5 The inquest 4F must be conducted by a senior coroner. When a person is detained, the State assumes responsibility for that person’s safety and for the provision of appropriate medical treatment.
As inmates are not free to seek out or obtain their own healthcare, it is particularly important
3 Section 81 Coroners Act 2009 (NSW).
4 Section 82 Coroners Act 2009 (NSW).
5 Section 27 Coroners Act 2009 (NSW).
that the treatment available to them meets an appropriate standard. Inmates should be provided with healthcare of a standard that is equivalent to what is available in the community.
On 15 October 2025, the State Coroner issued an open letter, identifying that 12 Aboriginal and Torres Strait Islander people had died in custody in New South Wales in 2025 – the highest number ever recorded in a single year. The State Coroner also noted that in the preceding 5 years, the number of Aboriginal people in custody had increased by 18.9 per cent while the non-Aboriginal prison population had declined by 12.5 per cent. Nearly half of Aboriginal adults in custody (45.6 per cent) were on remand or refused bail awaiting further court outcomes. The number of Aboriginal people on remand had surged by 63 per cent over the same five-year period. These figures reflect – consistently with the sentiments expressed by Greg’s family – that the entrenched over-representation of First Nations people in the criminal justice system is a systemic issue. I accept that this issue is grounded in the ongoing effects of colonisation. Until the broad causes of over-representation are properly addressed, the disproportionate number of First Nations deaths in custody will not reduce.
First Nations people are also known to experience inadequate health care and poorer health outcomes. This issue is well recognised by the government and certain measures have been adopted to “close the gap”. The gap has not closed. In this context, the importance of health screening and culturally safe care for all First Nations inmates cannot be overstated.
The Coroners Court of NSW remains committed to investigating every death in custody independently and thoroughly, in line with its statutory responsibilities. Inquests will continue to be conducted with impartiality, transparency and cultural sensitivity, ensuring that the voices of affected families and communities are heard and respected.
The evidence
The Court took evidence over four hearing days. It also received extensive documentary material contained within twelve volumes. This material included witness statements, medical and custodial records, photographs, audio calls and video footage, operational documents, and policies and procedures.
While it is not possible to refer to all of the material in detail within these reasons, I confirm the entirety of the evidence has been carefully reviewed and considered.
Prior to the commencement of the proceedings, a list of issues was prepared to guide the investigation.6 As is often the case, the inquest process served to crystallise the matters 5F requiring closer examination. I intend to address the most significant issues that emerged during the evidence under broad headings below.
Background and brief chronology
In addition to preparing submissions summarising much of the oral evidence, Counsel Assisting has prepared a chronological overview of the key events from the available documentary evidence. I have relied on these documents in recording my written reasons, at times adopting the submissions put forward. I have reviewed the evidence carefully where differences in fact, emphasis or recommendation are noted by the parties and in all matters the conclusions are my own.
I attach Counsel Assisting’s chronology as an annexure to these reasons. In my view it accurately sets out, in brief terms, Greg’s medical and custodial history as it was disclosed in the available documentary evidence before me.
The circumstances leading up to Greg’s death were not in dispute during these proceedings and the court had the benefit of CCTV footage as well as witness accounts.
On 27 December 2022 around 1pm a fight broke out between inmates in the common area of the MRRC wing where Greg was accommodated. Greg was not involved in the fight, and it is likely that he made verbal attempts to calm others as he is seen on the CCTV footage approaching the vicinity of the inmates who were fighting and then moving away as they moved towards him.
Several inmates became involved in the altercation, and one armed himself with a vacuum cleaner pole and began striking out. Tuna cans were thrown. Officers had legitimate concerns that someone could be seriously hurt. The Immediate Action Team, a tactical response team in the gaol, was summoned by correctional officers and arrived at the door of the POD at 1.08pm. CO Litasi Ma’u knocked on a window to the day room. He says he told the inmates to return to their cells. Shortly afterwards another officer opened the door to the POD and CO Ma’u discharged spray from a Magnum Fogger, while shouting at the inmates to return to their cells. In all there were three bursts of spray, which appeared to affect some inmates and staff in the direct vicinity. Greg was standing a few metres away. The CCTV footage shows 6 Issues List dated 6 March 2025.
Greg returning to his cell seconds after the spray was deployed. In a short period of time the inmates had all dispersed and were then locked into their cells by correctional staff.
He said he saw Greg “pacing and standing in the cell”.
At 1.40pm RN Harman arrived at Greg’s cell as part of a welfare check operation that nurses were conducting on all inmates. She saw Greg lying unresponsive in the shower area and she called for help.
Correctional Officers opened the cell. CPR was commenced and an ambulance called.
Tragically Greg could not be revived and was pronounced deceased at 2.30pm. There has been no submission that the medical response, once Greg was discovered unresponsive, was inappropriate or inadequate.
Greg’s physical health and management in custody Management of modifiable risk factors for myocardial infarction
Greg’s post-mortem examination determined his cause of death to be an “acute myocardial infarction” with the antecedent cause identified as “ischaemic heart disease”.7 6F
Associate Professor Mark Adams, Court-appointed Cardiologist, opined that at the time of death, Greg had advanced coronary artery disease, had sustained a previous myocardial infarction and likely had asymptomatic ischaemic heart disease. He noted that Greg was receiving no treatment for these conditions and had ongoing risk factors – particularly cigarette smoking, that predisposed him to a further myocardial infarction.8 7F
In his view, the major factor contributing to Greg’s fatal myocardial infarction was his preexisting severe coronary artery disease which had likely been present for some time and resulted from a combination of modifiable and non-modifiable risk factors.9 8F 7 BOE, Tab 3 (Vol 1) p.11.
8 BOE, Tab 5 (Vol 1) p.51.
9 BOE, Tab 5 (Vol 1) p.50.
A/Professor Adams considered that Greg received reasonable care for his cardiac condition, both in the community and custody. He observed that the first clinical manifestation of Greg’s cardiovascular conditions was the fatal myocardial infarction itself, and it did not seem that he had any cardiac symptoms beforehand. In such circumstances, the usual care would focus on controlling cardiovascular risk factors. For Greg, the most significant modifiable factors were smoking and long-standing hypertension, both of which are among the most important risk factors for the development of coronary artery disease. 10 9F
During Greg’s last period in custody (24 November – 27 December 2022), he was prescribed the medication perindopril, aimed at reducing blood pressure.11 In A/Professor Adam’s view,
10F this was reasonable.12
12F in custody, although this was ceased in the community.14
14F nothing else of his family history. At the time, she was focussed on addressing his hypertension. She expected to see him again, when she said consideration would have been given to commencing statins. Why these tasks could not be done at the same time remains unclear to me. Dr Dissanayake accepted she did not make a note in Greg’s Justice Health records, to consider statins. At the time, she was relatively new to Justice Health systems and stated that she did not know how to make a note on the Patient Administration System (PAS).16 Counsel Assisting submitted that considering the limited impact this would have had
15F on Greg’s risk factors, there would not be criticism of Dr Dissanayake’s approach.
10 BOE, Tab 5 (Vol 1) p.50, 53.
11 BOE, (Vol 9) Tab 78 p.2996; Tab 79 p.3086.
13 BOE, Tab 124 (Vol 2) p.3819.
14 Justice Health Records: BOE, Tab 78 (Vol 9) p.3705 (Crestor was commenced on 18 May 2020); Community GP Records from Pyrmont Medical Centre, Tab 71 (Vol 6) p. 1785 (Lipitor was ceased on 17 December 2020).
15 BOE, Tab 78 (Vol 9) p.3065 (Results).
While I find it hard to understand why Dr Dissanayake chose to delay consideration of a statin medication, I accept Professor Adam’s view that it would have had minimal impact on his overall risk of a heart attack. Nevertheless, given that inmates are routinely moved across the system and Dr Dissanayake may never have seen Greg again, her thinking in this regard should, at the very least, have been recorded in the record for future care givers.
A/Professor Adams raised an issue regarding the content of the discharge summary from St Vincent’s Hospital Sydney,17 which could have usefully commented on cardiac investigations
16F undertaken during Greg’s admission there in November 2022.18 St Vincent’s Hospital
17F acknowledged that ideally, the discharge summary would have referred to Greg having undertaken an ECG during the admission and recorded those results.19
Should Greg have received a Chronic Disease Screen during his final period of custody?
On 24 November 2022, following his RSA, Greg was placed on the waitlist for a CDS.21 It 20F follows that Greg ought to have had a CDS performed prior to his death on 27 December
This did not occur, and that was not consistent with policy.
Greg last received a CDS during a previous period in custody, on 22 January 2019 while housed at Parklea Correctional Centre (PCC). From April 2019, Justice Health ceased providing health services to patients at PCC and those services were subsequently provided by St Vincent’s Correctional Health (SVCH).22 The CDS identified that he had a chronic
21F 17 BOE, Tab 78 (Vol 9) p.2804.
18 BOE, Tab 5 (Vol 1) p.53. A/Professor Adams commented that it was recognised that Greg’s ECG showed a Wellen’s pattern consistent with possible significant coronary artery disease. Two further ECGs showed a similar pattern and a bedside echocardiogram in the emergency department is described as showing “global hypokinesis” suggesting significant underlying cardiac disease. Ideally this might have been further investigated, however, Mr Merriman was discharged against medical advice.
19 BOE, Tab 98 (Vol 10) p.3524 [20].
20 BOE, Tab 83, Annexure A (Vol 10) p.3110 [3.3].
21 BOE, Tab 81, line 18 (PAS excel spreadsheet).
22 BOE, Tab 78 (Vol 9) p.2854.
condition – arthritis. He was due to have a further CDS 12 months after that date. That did not occur.23 Counsel Assisting observed that there is a draft CDS in the Justice Health records
22F said to have been completed on 1 December 2019 and deleted on 18 June 2022 with comment “error”, when Greg was discharged from custody.24 Again, that was not consistent
23F with policy. Deb Little, Director of Nursing Regional – Primary Care, Justice Health, observed that Greg had nonetheless been reviewed by medical staff at SVCH and Justice Health on multiple occasions during his earlier period in custody which concluded on 12 June 2020.25
24F While I accept that this is correct, treatment for particular issues involves a different approach to the more wide ranging assessment which is required by a CDS.
Changes to Justice Health policy
All adult Aboriginal patients (and non-Aboriginal patients over 55) are also offered a Preventative Health Screen (PHS), within 12 months of the RSA. The PHS includes a screening process, with education health promotion. It can be opportunistic, and occur at the same time as another intervention, although is to occur within the timeframes above.
It was explained that the two pathways, namely the Chronic Condition Model and the PHS Model, separate patients into two categories:27
(a) patients who have been diagnosed with a chronic condition, who require management / monitoring / treatment; and
(b) patients who are considered to be at risk of developing a chronic condition, who may benefit from screening and the initiation of intervention strategies to prevent the development of chronic conditions.
24 BOE, Tab 78 (Vol 9) p.2879.
25 BOE, Tab 125 (Vol 12) p.3865 [16].
26 Exhibit 5, Letter from Hicksons Hunt and Hunt dated 14 October 2025.
27 Exhibit 5, Letter from Hicksons Hunt and Hunt dated 14 October 2025 [1.11].
increased focus on the prevention of chronic conditions, and to improve consistency of screening within existing resourcing constraints.
I am very troubled by the new time frame. The provision of adequate health screening is one of the very few possible positive outcomes for those who are incarcerated. Many Aboriginal inmates serve short sentences. If PHS is set to occurs towards the end of the 12 month window, many inmates will be released before it takes place. I am concerned the new policy constitutes a decrease in the level of service rather than a clear improvement.
Justice Health also identified further strategies to improve Aboriginal Health. Increasing the number of CCAs for Aboriginal patients who have been diagnosed with a chronic condition is one of the strategic goals of the Justice Health “10 Year Strategic Plan – 2023-32”. The implementation of the strategic outcomes outlined in Together for Healthier Tomorrows is being cascaded into a series of delivery plans with those plans being developed across fivetime horizons for each outcome. Horizon One is the initial set of actions within the broader 10-year vision to fundamentally rethink and improve healthcare in the custodial setting. The core objective is to transform service delivery to ensure safe, holistic, and equitable care, optimising patient health and wellbeing. A key activity for Horizon One is developing metrics to measure progress towards the strategic goals, ensuring accountability. To that end, Justice Health is in the process of designing and implementing an interactive dashboard which identifies patients who are due to undergo a CCA. It is envisaged that the dashboard will provide real time metrics in relation to CCAs, to the extent that patients who are due or overdue for their scheduled CCA will be more easily identified and prioritised.28
28F the Chief Executive of Justice Health submitted that while Justice Health does not have an update regarding the above strategies since its letter dated 14 October 2025, including on the resourcing necessary to implement those strategies, Justice Health affirms its continuous commitment to seeking to provide evidence based best practice to Aboriginal people in custody.
28 Exhibit 5, Letter from Hicksons Hunt and Hunt dated 14 October 2025 [4.1] – [4.4].
29 Exhibit 5, Letter from Hicksons Hunt and Hunt dated 14 October 2025 [4.5] – [4.8].
Was Greg’s cell placement appropriate during his final period of custody? What factors affected the cell placement decision?
• On Greg’s arrival at MRRC, RN Seok Yun performed an RSA.30 She explained her
29F practice in evidence, including to build a rapport, ask open questions and then ask in plain English, whether the patient had any relevant conditions.31 Among other
30F things, RN Yun made PAS waitlist entries, for drug and alcohol, mental health, methadone maintenance, blood pressure reviews and a CDS for hypertension and hyperlipidaemia.32
• RN Yun also completed a Health Problem Notification Form (HPNF). She recommended normal cell placement (NCP), meaning no specific clinical recommendation was given regarding cell placement. Although RN Yun had no recollection about completing the HPNF, she assumed she gave that recommendation because Greg looked well, was not exhibiting any distress, and had previous experience in custody. While he had raised blood pressure and a history of hypertension, he was not showing any symptoms.33
• Deb Little stated that, in her view, Greg met criteria for a shared or group cell placement, as this was clinically recommended when human contact and support are identified as being important requirements.34 She identified in evidence that it
33F was Greg’s history of anxiety and seizures, as well as his recent head injury, which would have led to this recommendation. However, this was at the outset, when little was known about the impact of those recommendations; Ms Little anticipated that this would have been reviewed during Greg’s time in custody.35
34F 30 BOE, Tab 78 (Vol 9) p. 2889.
32 BOE, Tab 81, lines 14-18 (PAS excel spreadsheet).
34 BOE, Tab 83 (Vol 10) p.3104 [34].
35F advantage to consider a two-out placement at the outset, given Greg’s head injury, RN Yun’s decision was reasonable in the circumstances known to her. It is also likely that this would have been reviewed at some point prior to Greg’s death.37 Counsel Assisting submitted
36F accordingly, Greg’s cell placement was appropriate.
The Solicitor Advocates on behalf of Shannon and Greg’s broader family, adopted the submissions of Counsel Assisting in this respect.
Decisions in relation to cell placement must weigh up a variety of factors, including the strong and understandable preference of some inmates for privacy. In all the circumstances, given the information known to RN Yun at the time of the RSA, I accept the decision to recommend Greg for NCP was one reasonably open to her.
Whether the deployment of CS spray on 27 December 2022 was a reasonably necessary use of force and in accordance with CSNSW policy?
37 There was a further HPNF completed on 1 December 2022, when Greg left COVID-19 quarantine. It recommended “Normal cell placement- lower bunk”. See BOE Tab 49, Folio 5(g) (Vol 3) p.957.
38 BOE, Tab 111 (Vol 10) p.3399 [8].
Cl 131 of the CAS Regulation: Use of force in dealing with inmates (1) In dealing with an inmate, a correctional officer may use no more force than is reasonably necessary in the circumstances, and the infliction of injury on the inmate is to be avoided if at all possible.
(2) The nature and extent of the force that may be used in relation to an inmate are to be dictated by circumstances, but must not exceed the force that is necessary for control and protection, having due regard to the personal safety of correctional officers and others.
(3) If an inmate is satisfactorily restrained, the only force that may be used against the inmate is the force that is necessary to maintain that restraint.
(4) Subject to subclauses (1)–(3), a correctional officer may have recourse to force for the following purposes— …
(h) to ensure compliance with a proper order, or maintenance of discipline, but only if an inmate is failing to co-operate with a lawful correctional centre requirement in a way that cannot otherwise be adequately controlled, …
(l) to restrain violence directed towards the correctional officer or other persons by an uncontrollable or disturbed inmate,
(m) to prevent or quell a riot or other disturbance,
(n) to deal with any other situation that has a degree of seriousness comparable to that of the situations referred to in paragraphs (a)–(m).
…
39F did not specifically think about giving a warning to inmates that they should get back to the cells or he would use CS gas.41
40F 40 BOE, Tab 106 (Vol 10) p.3353 [9].
He saw one of the inmates make a gesture which caused him to be concerned that he may have a blade. As a result, he did not give any warning.44
43 BOE, COPP 13.7, Tab 54 (Vol 4) p.1317 [7.5]; Warnings, Tab 61 (Vol 5) p. 1502; Tab 112 (Vol 5) p.3482.
for it) and advantages (it may result in compliance). In the present matter, the circumstances showed an immediate risk of serious injury, with the result that no warning was required. Mr Pese noted that, if force had been delayed, that may also have resulted in criticism.45
Counsel Assisting submitted, in light of that evidence, the use of force was reasonably necessary and was in accordance with CSNSW policy. Counsel for the Commissioner of CSNSW agreed with the submissions of Counsel Assisting on this matter.
The Solicitor Advocates on behalf of Shannon and Greg’s broader family, accepted that SCO Ma’u’s decision to use the Mace CS Fogger was reasonable with respect to the first two bursts but maintained that more should have been done in accordance with CSNSW policy to give a warning so that innocent bystanders could have had an opportunity to avoid the effects of CS gas. The Solicitor Advocates drew on the evidence Professor Alison Jones, Courtappointed Toxicologist and Specialist Physician Expert. Professor Jones commented that CS gas is more potent than OC spray, but both chemicals are broadly similar; they are designed to incapacitate people by making their eyes very sore and their skin sore to stop them from continuing with an aggressive type of behaviour.46
46F misapprehension that a warning was only required if the use of force was planned,48 not that
47F he made a specific decision not to give a warning due to the level of seriousness he perceived.
48F wasn’t part of the review of the use of force. They maintained he does not have a thorough understanding of what occurred.
gas was not reasonable and did not comply with cl 131(2) of the CAS Regulation, as it exceeded what was necessary for control and protection in the circumstances.
Further, SCO Ma’u and the IAT more generally, as seen in the video evidence appear to act decisively and responsibly in bringing the violent event to a conclusion effectively and with minimal application of force, limited to the three short bursts.
• Both of the CSNSW institutional witnesses, namely Mr Pese and Adam Riddell, A/General Manager of State-wide Operations, CSNSW, were of the view that in the circumstances, there was an imminent risk of serious injury or death and that in those circumstances a warning did not have to be given, in keeping with the first dot-point exception to the warning that otherwise “should be given”). While the Solicitor Advocates suggested that the exception did not apply to inmates; both of these witnesses gave evidence that the exception as apposite to the circumstances confronting the officers.50
• It would be perverse if IAT officers were not permitted to enter urgently, absent a warning, in circumstances where they held a concern about imminent risk of serious injury or death to an inmate (as distinct from themselves). On the interpretation sought by the Solicitor Advocates, the potential corollary would be that, in order to protect the safety of inmates, officers may feel compelled to enter without the aid of chemical munitions, in which circumstances they would potentially expose themselves to risk of serious injury.
• Mr Riddell confirmed that relevant warnings are to be given only if time and circumstances allow.51 Further under COPP 13.7, Use of Force, the requirement to
50F give warnings in the case of planned use of forces generally is qualified by the proviso that this is the case “unless urgent intervention is required.”52
Ultimately, Counsel for the Commissioner submitted that in the circumstances, no criticism is warranted of the actions of the IAT officers on the basis that they did not give a formal warning concerning the deployment of chemical munitions.
I have considered the matter carefully and am persuaded the use of CS spray was broadly consistent with the relevant policies. I accept, given the large number of prisoners present, that officers had a legitimate concern that the situation could escalate quickly and that serious injury or death could result. A verbal warning was not given, but as the IAT officers burst into the common area, shouting at inmates to return to their cells it would have been immediately clear that SCO Ma’u was holding a spray cannister ready to use. It is well known within the prison system that IAT officers have the capacity to use spray in circumstances where serious harm is contemplated. While the threat may have decreased after the second spray, the third use of spray follows almost immediately and in my view occurred at a time when it was open to the relevant officer to hold the view that risk of serious harm remained. I accept there may have been an opportunity for the Correctional Officer (CO) to pause and warn before the third spray, or to make a decision that two sprays were sufficient for the threat encountered, but I am not critical of the officer in this regard. In the spur of the moment risk of this sort may be assessed differently by individual officers tasked with the decision of whether or not to use force.
Was a reasonable and adequate process undertaken to check inmates’ welfare, following the use of force incident which occurred on 27 December 2022?
(a) COPP 13.7, Use of Force, requires staff to request Justice Health NSW to medically assess or treat an inmate who is subject to a use of force, regardless of the presence or absence of injury.53 There is also guidance and training for chemical munitions
52F operators on personal and area decontamination.54 There is no specific guidance or
53F policy on medical or welfare checks on bystanders, following deployment of CS gas.
52 BOE, Tab 114 (Vol 10) p.3502.
53 BOE, Tab 52 (Vol 4) p.1313 [6.1].
54 BOE, Tab 111 (Vol 12) p.3466-3468.
(b) The process that was adopted in the present case was that the POD was placed into lock down, and a request was made to Justice Health to attend to check inmates.
No immediate steps were taken to identify or decontaminate affected inmates other than those directly targeted in the use of force. A head check was performed, and none of the inmates checked appear to have raised any concern.
• The CCTV shows that Greg returned to his cell about 4 seconds after the CS gas was deployed. CO Satnam Singh then looked into the cell briefly and shut the door.
The door was locked by Functional Manager (FM) Daniel Hewson, at 1.09pm.
Neither CO Singh nor FM Hewson had a particular memory of Greg’s condition at that point.
• At 1.15pm, CO Meznaric attended Greg’s cell, opened the hatch and briefly looked inside. He described this as a “head check”, which FM Hewson had asked him to perform. He recalled seeing Greg “pacing and standing”. He was 100% confident about this; if he had seen something wrong, he would have taken action.56
• By 1.18pm, the IAT had completed processing inmates in the dayroom and the yard, and all inmates had been locked in their cells. All officers then left the day room. No-one re-entered the day room until 1.38pm, 20 minutes later.
• Meanwhile, CO Pradap, in the clinic, received a call requesting a medical check.
It is uncertain when this call was made. He then attended the POD with two nurses, RN Ian and RN Harman.
• RN Ian can be seen for the first time on the video at 1.26pm. She appears to be looking into the day room, to observe the state of the POD.57
• The evidence does not reveal precisely why there was a delay between the attendance of the nurses and their entry into the POD. At least some of the time was taken up with a handover, and some required for RN Ian to attend the clinic to obtain a third nurse. All three nurses and CO Pradap entered the day room.
55 BOE, Tab 48 Folio 6(b)(i); Exhibit 2, Bodyworn camera footage “UOF_GAS_Pod_26_R_block_IAT”.
• There was no prioritisation for the review of the inmates, and the nurses simply commenced on the left and worked around. However, identifying any inmates who were at greater risk would have added further delay.58 In any event, the lapse
57F of time between the time when nurses attend the first cell and Mr Merriman’s cell was about 2 minutes.
58F be of benefit for there to be such guidance, including on the need to identify who is affected by gas, contact with Justice Health, and first aid and decontamination. Justice Health has already drafted relevant policy. It would be an advantage for CSNSW and Justice Health to ensure their policies align. This informs a proposed recommendation put forward by Counsel Assisting, which will be dealt with in the recommendations section below.
The Solicitor Advocates on behalf of Shannon and Greg’s broader family, adopted the rationale in the closing submissions of Counsel Assisting for this issue, except to note that on the totality of the evidence, there was no identifiable reason for the delay in CSNSW officers facilitating the entry of Justice Health nurses into the POD for welfare checks. They commented that this was concerning and the lack of reasons for this means the delay was not reasonable.
Counsel for the Commissioner contended that the time between the arrival of Justice Health nursing staff in the POD at 1.26pm and their deployment on the floor for the purpose of conducting checks at 1.38pm was not inordinate, nor were the events over that 12 minute period fully explored in evidence, but it is known that at least some of the time was taken with a handover, and some required for Nurse Ian to attend the clinic to obtain a third nurse. It was submitted that there is not a sufficient basis to conclude that there was any delay that was “not reasonable”.
In terms of the effects of the CS spray, the Solicitor Advocates referred to the evidence of GW, an inmate in R Block on 27 December 2022 who was not involved in the fight. From his recollection, the CS spray “made it very hard to breathe. Tight chest … it wasn’t nice. It was pretty horrible actually.” 60 SCO Ma’u also agreed that his and a female colleague’s breathing
59 BOE, Tab 111 (Vol 10) p.3437.
was affected.61 GW further gave evidence that if a warning had been issued, he would have
60F gone outside as fresh air “is the best way to stop the effects of the gas.”62 Mr Pese outlined
61F in his statement that chemical munitions operators are taught that “the best first aid after being exposed to CS is fresh air/wind.”63
What factors contributed to Greg’s acute myocardial infarction?
63 BOE, Tab 53 (Vol 4) p.1098.
66 BOE, Tab 5, (Vol 1) p.50-51.
67F Greg’s prescribed medications or the substances detected post‑mortem were likely to have contributed to the fatal event.69
Nevertheless, if this myocardial infarction did not occur at this time, it was virtually inevitable that it was going to occur at some stage in the near future given the severity of his coronary artery disease.”70
68 BOE, Tab 5, (Vol 1) p.52.
69 BOE, Tab 5, (Vol 1) p.52.
70 BOE, Tab 5, (Vol 1) p.53.
OC spray / CS gas
The evidence in relation to the discovery of traces of OC spray, rather than CS gas on Greg’s body caused considerable confusion during these proceedings.
Swabs were taken of Greg’s hands and face on 30 December 2022. Testing conducted on these swabs revealed traces of the main components of OC spray, on Greg’s left hand and face. Testing did not reveal any exposure to CS gas.72
72F shorts; it is possible that there had been some exposure to CS gas, which evaporated to undetectable levels, prior to testing in October 2025.74 However, this is speculative.
74F positive finding can be made as to the origin of the OC spray and frustratingly it remains a mystery.
There is, no evidence that Greg was exposed to any significant dose of CS gas during the use of force incident.
At the time of their reports, A/Professor Adams and Professor Alison Jones were each asked to consider whether exposure to OC spray contributed to Greg’s heart attack. Neither considered it to have contributed to the death, because, on a review of the video evidence, Greg did not appear to have had a large exposure.76
75F 72 BOE, Tab 4 (Vol 1) p.49.
73 Exhibit 3, FASS Chemical Criminalistics Unit Report dated 30 September 2025.
74 Exhibit 6, FASS Chemical Criminalistics Unit Report dated 30 October 2025 [8.14].
75 Exhibit 6, FASS Chemical Criminalistics Unit Report dated 30 October 2025 [6.3].
76 BOE, Tab 5 (Vol 1) p.53; Tab 101 (Vol 10) p.3276.
Counsel Assisting submitted that the only contributing condition to Greg’s heart attack which is clearly supported by the evidence is Greg’s pre-existing cardiovascular disease termed as “ischaemic heart disease” by the pathologist.
After listening to the experts I am confident that I can discount the CS spray as a direct factor in Greg’s death. I have watched the CCTV footage a number of times and I accept that even if he was affected to some degree, he was not in the path of a direct blast.
While the stressful context of Greg’s return to his cell may have raised his blood pressure and heart rate, it must be emphasised that Greg had significant pre-existing disease which is the root cause of his untimely death.
The need for Recommendations
Counsel Assisting put forward one recommendation arising from the evidence directed at CSNSW. The recommendation was drafted in these terms: To the Commissioner of Corrective Services NSW:
CSNSW to consider amending Custodial Operations Policy and Procedures 13.7 – Use of Force, to include further instructions on action to be taken by correctional officers following the deployment of chemical munitions, including: a) identifying inmates who are affected by gas or are otherwise in need of medical attention, b) contact required with Justice Health staff, c) first aid and personal decontamination, and d) decontamination of areas affected by chemical munitions.
The Solicitor Advocates on behalf of Shannon and Greg’s broader family, supported this recommendation in principle, but sought the following specificity: “That COPP 13.7 is amended to state that the best way to decontaminate inmates and provide first aid to who may have been exposed to CS gas is to give them access to fresh air/wind and not to lock them in their cells”.
• it is consistent with the approach taken by Justice Health;
• it accommodates the fact that there may not always be an on-site Justice Health presence, depending on location and timing; and
• it adequately accounts for the fact that the deployment of chemical munitions may occur in a range of different environments and circumstances and may or may not entail issues concerning possible effects on inmates who are “bystanders”.
The circumstances must also be sufficiently secure so that Justice Health clinicians can safely provide assistance to inmates.
Having considered the submissions on this issue, it is in my view appropriate to make the recommendation in the terms suggested by Counsel Assisting.
The Solicitor Advocates on behalf of Shannon and Greg’s broader family, put forward a draft recommendation arising from the evidence, directed at Justice Health. The recommendation was drafted in these terms: 78 T142: 45-49 (30 September 2025).
To the Chief Executive of Justice Health & Forensic Mental Health Network: Consider undertaking a review of its systems to ensure the following occurs, or otherwise, is implemented: a) That information is obtained upon entry into custody from NSW Police and/or CSNSW of recent hospital admissions following arrest and reviewed prior to the RSA; b) That health information is obtained from community and external healthcare providers early; c) Health information is being reviewed by health staff regularly upon treatment of an inmate; d) Previous health information that is known to Justice Health being populated into new systems; specifically, family history being auto populated into CCA’s and PHS; and e) Consideration be given to family history being included in the RSA and auto populating if known.
80F They submitted that if a CCA had been performed on Greg during his final period in custody, this would have assisted clinicians to consider his hypertension in the context of cardiovascular disease and in circumstances where he was previously commenced on statin medication during his earlier period in custody.82
81F 79 BOE, Tab 40 (Vol 2) p.440; Tab 49, Folio 4 (Vol 3) p.850.
80 T52:44-50; T53:6-14 (29 September 2025); T53:6-14 (1 October 2025).
81 BOE, Tab 78 (Vol 9) p.2857.
82 BOE, Tab 78, (Vol 9) p.3705.
82F concerning that the Justice Health records which would have been available to Dr Dissanayake through the Justice Health Electronic Health System (JHeHS), indicated that Greg had a family history of cardiovascular disease.84
This is a statewide clinical portal which provides clinicians with immediate access to an aggregated view of patient and clinical information from NSW Health clinical systems and My Health Record. The information available through HealtheNet includes but is not limited to discharge summaries from recent hospital admissions.
Finally, timely access to information about recent hospitalisations will be further enhanced when the Single Digital Patient Record (SDPR) is rolled out. This is a platform that will provide NSW Health care teams access to an integrated all-in-one electronic medical record system, patient administration system and pathology laboratory information system. Handover documents from external hospitals and specialist health services will include admission and discharge documents recorded in the same record.
84 BOE, Tab 78 (Vol 9) p. 2744-2745; 2782-2783, 2821, 2857, 2882.
b) Justice Health currently seeks information from community and external healthcare providers at an early stage in a patient’s interaction with the criminal justice system through the ROI process. Further the HealtheNet is available to all Justice Health clinicians, and the SDPR will enhance timely access to relevant information.
c) Standard clinical practice requires practitioners to review the patient’s health record when reviewing and treating the patient.
d) The evidence before the Court does not permit a conclusion that auto population of family history information would provide efficiencies or improvements in clinical practice, particularly given that the matter was not raised in evidence in terms of whether Justice Health has previously explored the use of auto population within JHeHS and whether it is possible and achievable from a resourcing and technology perspective.
e) Specific questions about family history are asked during a CCA or PHS assessment, family history may be captured opportunistically, or through material obtained through the ROI process. The RSA is a different process to a CCA or PHS. It is a screening tool for the purpose of identifying active health issues for a patient upon their entry into custody to ensure appropriate referrals are made, appropriate cell placement recommendations are made, and any immediate treatment needs are met. To achieve this objective, the RSA comprises a large number of screening questions and can take anywhere from 30 minutes to an hour and a half to complete.
In those circumstances, and where Justice Health processes already seek to capture family history information, it was submitted that it is of limited benefit to add family history to the RSA process.
I have carefully considered the response provided by Justice Health in relation to the family’s concerns. I accept that the system will be improved once the SDPR is rolled out. This appears to be a more appropriate way to obtain information than by requesting it through NSW Police or through CSNSW.
It appears to me that in the circumstances of this case, even under the current system, important information would have been provided to Justice Health at an early stage had the St Vincents Hospital discharge summary been a more robust document.
I am sympathetic to the family’s concerns that had further information (including information about family history), been available or accessible to Justice Health a more complete picture of Greg’s risk would have been available and as a result planning for his care may have been improved. It appears that a comprehensive PHS would satisfy some of these concerns. In
this regard I have already raised my concerns about the current timeframes for the completion of a PHS. I have also stated that resources to implement contact with Aboriginal Health workers within weeks of the RSA should be provided as soon as possible. It strikes me that Justice Health has appropriate plans and is keen to strengthen the service it provides for Aboriginal inmates, but is hampered by resourcing restraints. This is unacceptable.
Findings and Recommendations
Date of death Greg died on 27 December 2022.
Place of death Greg died at the Metropolitan Reception and Remand Centre, Silverwater NSW.
Cause of death Greg died from acute myocardial infarction caused by ischaemic heart disease.
Manner of death Greg died while he was lawfully detained as an inmate in a correctional centre. Following a lawful use of force where Orthochlorobenzalmalononitrile (CS gas) was deployed against other inmates, Greg was locked inside his cell. He was discovered unresponsive about 30 minutes later. His death was a result of natural causes.
Recommendation pursuant to section 82 Coroners Act 2009
For the reasons stated above, I make the following recommendations pursuant to section 82 of the Coroners Act: To the Commissioner of Corrective Services NSW
CSNSW to consider amending Custodial Operations Policy and Procedures 13.7 – Use of Force, to include further instructions on action to be taken by correctional officers following the deployment of chemical munitions, including: a) identifying inmates who are affected by gas or are otherwise in need of medical attention, b) contact required with Justice Health staff, c) first aid and personal decontamination, and d) decontamination of areas affected by chemical munitions.
Conclusion
I thank the OIC, Detective Senior Constable Jemima Brown for her assistance in these proceedings.
I thank Nicolle Lowe, Aboriginal Coronial Information and Support Program worker. Her role at this court is of the utmost importance and once again she has assisted a grieving family to make sense of these difficult proceedings. Her assistance to this Court is once again invaluable.
I thank Mr Jake Harris of counsel and his instructing solicitor, Ms Connie Livanos for their hard work in the preparation of this inquest.
Magistrate Harriet Grahame Deputy State Coroner, Coroners Court of NSW, Lidcombe 6 March 2026
Attachment – Counsel Assisting Chronology Date Time Event Ref e 4 Dec 1964 00:00 Greg is born (58 at death) P79A 2 0002 1972 Greg is placed in Daruk Boys Home until he is 17 He is the victim of physical and sexual abuse 1976 First criminal charge, stealing (aged 11) OIC 8 [20] 0206 Crim hist 42 0488 1977 Commences smoking cannabis, and later uses amphetamines, LSD and heroin (at 18) u/k Greg is placed in Mount Penang Training School OIC 8 [20] 0206 for Boys, where he suffers abuse. He later assisted police with an investigation into child abuse offences at that facility, and Dharruk 1984 Greg is hit on head with sledgehammer.
Following this, he experiences seizures 1985 First enters custody (aged 21) OIC 8 [20] 0206 1988 Commences methadone u/k Father dies of CVD aged 49; mother also has CVD 1985 to Various prior periods in custody IPD 49 (2) 0624 2009 9 Feb 2009 Enters custody 7 Feb 2012 Released from custody 2013 Commences methamphetamine use 7 Nov 2013 Lipitor 20mg is first prescribed (for cholesterol) Pyrmont 71 1748 10 Jan 2014 Greg falls and sustains a head injury 12 Jan 2014 Greg has a seizure; he is treated at Wyong Hospital. No clear epileptic activity detected 1 Sep 2014 Review by neurologist: In view of the history, this man needs to be on an anti‐epileptic drug long‐term and he has agreed to go on Keppra building up to a dosage of 500mg b.d if tolerated 14 Mar 2016 Enters custody at Surry Hills IPD 37 15 Mar 2016 Transferred to Parklea CC IPD 37
Date Time Event Ref e
RSA JH 64 No history of cardiovascular issues or hypertension noted 12 Apr 2016 Blood tests JH 78 Pathology 3069 Cholesterol 5.6 H 3.0-5.5 Triglycerides 1.98 N <=2.0
HDL 1.1 N >=0.9 LDL 3.6 H (<=3.5) Cholesterol total/cholesterol in HDL 3.7 Non-HDL cholesterol 3.8 (<=4.0)
HB1AC 4.7 N 4.0-6.0 3066 13 Apr 2016 ROI sent to Broadway Medical Centre JH 78 2737 15 Apr 2016 ROI received from Broadway Medical Centre JH 78 2739 Patient records include that he is a smoker, Medication fluoxetine (Lovan), Valium and Panadeine Forte 2 May 2016 ECG – suggests Left Ventricular hypertrophy JH 78 2744 15 Sep 2016 Released from custody IPD 37 In community 6 Oct 2016 Enters custody at Surry Hills IPD 37 Has a seizure; taken to RPAH ED for assessment JH 78 2761 7 Oct 2016 Transferred to MRRC IPD 37 7 Oct 2016 ROI sent to Pyrmont Medical Centre JH 78 2746 ROI received from Pyrmont Medical Centre JH 78 2748 Patient records include IV drug use, Hep C.
Medication - methadone, Valium 28 Nov 2016 Transferred to John Morony CC IPD 37 1 Dec 2016 Released from custody to CDTP IPD 37 Commences Compulsory Drug Treatment Program, Phase 1 30 Mar 2017 Progresses to Phase 2 18 Jul 2017 Dr Maria Li, GP JH 78 2768
Date Time Event Ref e Has put on weight (100kg) and attributes it to Avanza. Blood tests requested including lipids 3 Aug 2017 Progresses to Phase 3 22 Jan 2018 Blood tests from GP JH 78 2775 T cholesterol 5.4 N Triglycerides 1.9 N
HDL 0.8 L (>0.9) LDL 3.7 H (<3.5) Received in ROI 12 Feb 2018 Just prior to completing the CDTP, Greg relapses, in the context of being interviewed by police in relation to an historic child abuse investigation (perpetrated against him) 7 Feb 2018 Charged with Larceny, Entering premises without lawful excuse, Break and Enter Enters custody at Surry Hills IPD 37 10 Feb 2018 Transferred to MRRC IPD 37
RSA JH 78 2822 History of seizures and arthritis is noted Methadone use – last dose 7 Feb 12 Feb 2018 ROI sent to Pyrmont Medical Centre and Star JH 78 2765 Medical centre ROI received from Star Medical centre JH 78 2771 2775 Includes blood tests from 22 Jan 13 Mar 2018 Transferred to Parklea CC IPD 37 14 May 2018 ECG – possible inferior myocardial infarction JH 78 2782 22 Jan 2019 Chronic Disease Screen (RN Foxhall) JH 78 2854 Arthritis Seizures Multidisciplinary Care Plan JH 78 2858 Arthritis – plan to review by GP after X rays
Date Time Event Ref e 23 Jan 2019 Blood tests JH 78 Pathology 3057 Cholesterol 5.7 H 3.0-5.5 Triglycerides 2.86 H <=2.0
HDL 0.81 L >=0.9 LDL 3.6 H (<=3.5) Cholesterol total/Cholesterol in HDL 7.0 normal 27 Sep 2019 Medication perindopril (for hypertension) JH 123 3729 8 Mar 2019 Sentenced to 3 years 4 months’ custody 1 Dec 2019 11:11 Chronic Disease Screen (RN Divina Velasco) JH 78 2879 Deleted on 18 Jun 2022 Assessment date is 1 Dec 2019 16 Dec 2019 Transferred to MSPC IPD 37 21 Dec 2019 PAS waitlist PAS waitlist 81 Line 31 Requesting initial CDS Priority 4 = Routine This line is still outstanding on 12 Jun 2020 Jan 2020 Chronic Disease Screen is due (12 months) 18 Mar 2020 D&A review – methadone to be increased to JH 78 2961 140mg max for pain management 27 Apr 2020 Blood tests JH 78 Pathology 3064 Cholesterol 7.5 H 3.0-5.5 Triglycerides 5.7 H <=2.0
HDL 0.8 N 0.7-1.9 LDL 4.1 H (<=3.5) 18 May 2020 Dr Miljan Vlahovic review JH 78 2979 Lipid profile deranged - Fasting bloods confirmed with Pt.
Pt is going home in 3/52,
O/E Looks well
BP 130/70 HR 68 Hyperlipidaemia discussed.
Adequate diet, exercise discussed Side effect of Crestor discussed Pt advised to see his GP as soon as he can.
Reminded about his referral to POWH for Colonoscopy
Date Time Event Ref e Medication Crestor (rosuvastatin) JH 78 3705 11 Jun 2020 Fax to Broadway General Practice JH 78 2985 Release Summary & transfer of care sent to GP 12 Jun 2020 Released on parole IPD 37 Supervised by Community Corrections 23 Nov 2020 TTE performed at RPAH 2637 Reveals aortic dilation and mild aortic regurgitation, and L ventricular hypertrophy 17 Dec 2020 Dr Maria Li (GP) Pyrmont 71 1785 Blood results given - after ringing RPAH pathology to fax to us. No diabetes, nor high lipids Lipitor is ceased [for cholesterol] 18 Dec 2020 Admission to RPAH RPAH 76 2450 Admitted on an involuntary basis following assessment at Drug Health clinic 19 Dec 2020 Discharged 8 Jan 2021 Call from RPAH D&A to Dr Maria Li – re Pyrmont 71 1786 admission to RPAH over Christmas 12 Jan 2021 Dr Maria Li (GP) Pyrmont 71 1786 Attends re rectal bleeding and for Valium prescription Brought up aortic root dilatation and concentric LV hypertrophy, which is related to his untreated hypertension. Pt recalls when his BP was checked in jail it was high too.
D/W pt and needs cardiac assessment and treatment of his hypertension, monitoring of his aortic root dilatation Greg is referred to cardiologist Prof I Wilcox Mar 2021 Greg receives compensation for historic abuse OIMS 49 Folio 7a 1043 12 Apr 2021 Parole supervision ends SIR 49 [1]
Date Time Event Ref e 13 Apr 2021 OIMS note: SIR 49 [42] 0603 OIMS 49 Folio 7a 1045 Greg’s response to supervision during his parole period was satisfactory … He has never missed an appointment and has maintained his methadone treatment at RPA. … He would often talk about his child hood trauma which he said attributed to his mental health, drug use and his offending… He reported being at peace in his life and wants to put his offending behind him and become a mentor for young indigenous people … 14 Apr 2021 Admission to RPAH RPAH 76 2481 Greg is hit by a reversing truck and sustains a head injury. Concussion, L frontal subdural haematoma, non-displaced fracture of occipital bone 19 Apr 2021 Discharged 26 Apr 2021 Dr Maria Li – review re head injury Pyrmont 71 1788 13 May 2021 Presentation to RPAH ED - psychosis RPAH 76 14 May 2021 Discharged 23 Jul 2021 Charged with custody of knife Criminal history 42 0554 Fined $1,000 28 Oct 2021 COVID vaccine given (first dose) JH 78 2931 Immunisation 70c 1738 18 Nov 2021 COVID vaccine given (second dose) JH 78 2931 Immunisation 70c 1738 15 Feb 2022 Charged with possess prohibited drug Criminal history 42 0554 Fined $300 11 May 2022 Admission to RPAH RPAH 76 2663 Involuntary admission in the context of auditory command hallucinations 13 May 2022 Discharged 23 May 2022 Charged with possess drugs, drive unlicenced Criminal history 42 0554 Later withdrawn (deceased) 25 May 2022 Dr Maria Li Pyrmont 71 1793 Attends for MHCP.
Last attendance on GP prior to death
Date Time Event Ref e 5 Sep 2022 Dr Mark Lentham Broadway 73 2196 Greg is seeking diazepam
BP 155/98 HT noted 11 Sep 2022 Dr Leilani Seeto Star City 74 2355 Greg seeks a medical certificate for court 21 Sep 2022 Fails to attend court - Bench warrant issued CMR 40 p17 0443 2 Nov 2022 Greg is alleged to have entered a residence in Facts sheet 41 p2 0458 Chatswood, and take multiple items He is connected to the scene by fingerprints 4 Nov 2022 Greg is alleged to have entered a private Facts sheet 41 p8 0464 property Lidcombe, where he took multiple items He is connected to the scene by fingerprints 5 Nov 2022 Greg suffers a head injury Greg is found by police slumped on a parked motorbike, intoxicated 15:51 Admission to St Vincent’s Hospital ED St Vincents 75 2372
JH 78 2809 17:37 Drug screen – positive for benzodiazepines, St Vincents 75 2418 amphetamines, cocaine, cannabis, alcohol, JH 78 2806 methadone – he admitted use CT brain, spine, chest, abdomen, pelvis. Multiple St Vincents 75 2418 facial fractures noted, no other acute injury. 2419 Not for immediate surgery – for follow up in plastics clinic ECGs – consistent with hypertension and old MI. St Vincents 75 2383 The ECG is marked ? Wellen’s syndrome Keep on St Vincents 75 2438 monitor Rpt in 15/60.
However, Troponin tests do not reveal cardiac injury (13).
No further cardiac investigations are undertaken or recommended 6 Nov 2022 Discharged against medical advice
Date Time Event Ref e Discharge summary: St Vincents 75 2418
OIC 8 [21], [49] 15 Nov 2022 Presents to RPAH D&A feeling dizzy, nauseous RPAH 76 2813 and with headache Presentation to RPAH ED RPAH 76 2673 Greg states he was assaulted 3 days prior.
Diagnosed with post-concussion syndrome.
Reviewed by D&A team, discharged to continue methadone as planned CTB / CTX – discharged with head injury sheet Discharged 17- 21 Nov Methadone 140mg dispensed daily Tab 64 p56 2022 22 Nov 2022 09:24 Methadone administered at RPAH JH 78 2791 14:40 Arrested at Ultimo OIC 8 [1] 0203
SIR 36 [2] Charged with break and enter offences, and outstanding warrants for possess drug, drive without licence, enter enclosed lands Complains of pain and light-headedness OIC 8 [2] following a previous head injury Pinched nerve in back; 2 fractures in head from
CMR 40 11 days ago from assault
CMR 40 Shaking, shielding face from light, states that he is suffering from pain and light headedness from an injury to skull a week ago – ambo called 15:33 Ambulance called, but cancelled due to wait, OIC 8 [2] 0203 taken by police to St Vincent’s CMR 40 p25 0451 16:31 Presentation to St Vincent’s Hospital ED St Vincents 75 2421 17:42 Dr Rahul Santram (emergency physician) JH 78 2804 CMR 40 p14 0440 Recent Zygomatic fractures and orbital floor# - uncomplicated -> has a plan to F/u in plastics clinic. Recent review at RP A and had CT brain – no intracranial pathology
Date Time Event Ref e For simple analgesia (Paracetamol and Ibuprofen). Confirm F/u at Plastics Clinic (ph: 8382 3110) Medically cleared for discharge into police / corrective services care 18:49 Returned to police station CMR 28 20:11 Charged with break and enter x 2, Dishonestly CMR 28 obtain financial advantage CAN 29 23 Nov 2022 Methadone is not dispensed on 23 Nov 04:01 Refused bail CMR 40 p4 0431 Enters custody at Surry Hills CC IPD 37 NILSIS Case man 49 Folio 0860 Inmate shielding face from the light. Sensitivity due to head injury from a week ago. Treated at hospital. Clearance attached Downing Centre Local Court – refused bail OIC 8 [3] Warrant 49 Folio 3(e) 0784 Remanded to 7 Dec 2022 11:16 Reviewed by NUM Thirak Keo JH 78 19:49 ROI to RPAH for methadone dosing JH 78 2790
JH 79 3089 24 Nov 2022 Section 23 Reception transfer checklist Case man 39 08:28 ROI received from RPAH – last dose 140mg JH 78 2791 dispensed on 22 Nov at 9.24am JH 79 3091 09:27 Review by NUM Keo prior to transfer JH 78 2989 12:20 Transferred to MRRC IPD 37 Placed in reception holding cell OIMS housing 52 1096 Inmate application form Case man 49 Folio 4 0802 I Gregory Merriman wish to remain on protection over my brother laws murder [name intentionally omitted] in long bat R wing Placed on SMAP SIR 49 [4] 0596 Case man 49 Folio 4 0794 Care 49 Folio 8e 1065 13:19 EN Richards – review on intake. Greg says he JH 78 2990 hasn’t received methadone since Monday
Date Time Event Ref e 13:38 Intake Screening Questionnaire (Isabel Burns) Burns 22 0302 14:07 Case man 49 Folio 4 0850 Head and back injury, recent head injury Contact established with inmate’s sister Kerry ROBERTSON on [number intentionally omitted].
Inmate became emotional and cried, stating to his sister that he felt that he had not been taken care of in custody as he has not been dosed. Call appeared supportive and inmate ceased crying by its conclusion … (stated he has a head injury and is having headaches when looking at the light) No issues raised, other than headache. Provided with handbook 15:05 Methadone 140mg is dispensed JH 79 3095 16:39 HPNF (RN Seok Yun) SIR 49 folio 5(e) 0955 Case man Folio 4 0838
JH 79 3079 Previous experience in custody Chronic lower back pain On Methadone program Denies current thoughts of self-harm / harm to others and suicidal ideation Normal cell placement – lower bunk Quarantine until cleared by Justice Health 16:45 Reception Screening Assessment (RN Seok Yun) JH 78 2889 Aboriginal Existing active health conditions Arthritis Physical disability Seizures History of Cardiovascular Condition No Methadone 140ml Current medication paracetamol, ibuprofen and diclofenac BP 151/86 | HR 66 | SpO2 100% | T 36.2 | RR 16 BGL 7.9 | H 177cm | W 78kg | BMI 24
Date Time Event Ref e Admits smoking Ice, 1-2 points, 1-2 days per week, last used 2 weeks prior Reports depression and anxiety, but no report of heart problems or hypertension D&A MH Summary provided to CSNSW Case man 39 Consents obtained for St Vincent’s, RPAH, JH 79 3080 Pyrmont PAS waitlist PAS waitlist 81 Line 14 Drug and Alcohol - New reception 24/11/22 - Recent head injury HTN, Hyperlipidaemia - currently a/w CDS blood. Epilepsy (seizure free for 5 years as per pt) Priority 2 = semi-urgent Adult Ambulatory Mental Health - Hx of dep but Line 15 recent head injury/referred to GP Primary health - New reception 24/11/22 - on Line 16 MMT 140mg. ICE smoke "here and there" 12points LUD 2/52 ago.
Priority 3 = non-urgent Primary health - Repeat BP please. if possible Line 17 please attend CDS blood/ECG Priority 3 = non-urgent Primary health - CDS - HTN/Hyperlipidaemia Line 18 Priority 3 = non-urgent PM Medication Paracetamol, Ibuprofen JH 79 3083 Methadone prescribed by Dr Kehoe OST 65 D&A OST Program details (RN Boorer) JH 64 H 182cm | W 92kg [error?] 17:05 Placed in Darcy Unit 2 Cell 73 OIMS housing 52 1096 25 Nov 2022 COVID quarantine checks commence (until 30 JH 64 Nov) PM Medication Paracetamol, Ibuprofen JH 79 3083 Methadone 140mg is dispensed JH 79 3095 PAS waitlist – PH nurse 4 (routine) PAS Wait line 12 ECH post quarantine ROI sent to Pyrmont Medical Centre JH 78 2795
Date Time Event Ref e ROI received from Pyrmont Medical Centre JH 78 2797 Medications: Celebrex 100mg (anti-inflammatory) Methadone 5mg/mL Nexium 40mg (heartburn) Valium 5mg No mention of hypertension/heart issue On 12th November 2022, Greg sustained head injury and laceration to his brow from as alleged assault. He was seen in Emergency, RPAH and CT brain and spine revealed occipital skull fracture.
No surgery was deemed necessary, but he was diagnosed with post-concussive syndrome.
ROI sent to St Vincent’s JH 78 2798 ROI from St Vincent’s JH 78 2799 Discharge summary from 6 Nov 2022 Check up 22 Nov 2022 Methadone dosing chart ECG not included - CT scan refers to dilated aorta ROI sent to RPAH JH 78 2811 ROI received from RPAH JH 78 2813 Discharge summary 15 Nov 2022 Hypertension … Mild AR and aortic arch dilation 11:20 RN Bridget Musarurwa (D&A review) JH 78 2991 Patient not intoxicated or withdrawing
Placed on waitlist for 3/12 MMT
Placed on waitlist for ECG post quarantine
Waitlist active in PAS for PH r/v of elevated BP
NIM as required
Advised to knock up if any issues or concerns arise 26 Nov 2022 PM Medication panadol, Ibuprofen JH 79 3083 Methadone 140mg is dispensed JH 79 3095 27 Nov 2022 Methadone 140mg is dispensed JH 79 3095 OTS call to Kerry Robinson OTS 49 Folio 8h 1075
Date Time Event Ref e Last successful call to Kerry-Anne 28 Nov 2022 Classification and Placement Team meets to OIC 8 [70] consider initial classification. Greg is not Bhalla 28 0309
SIR 49 [31] present. Hardeep Bhalla informs Greg of the OIMS 49 Folio 7b 1048 outcome Initial classification: B (Unsentenced) Case man 49 Folio 4 0826 Methadone 140mg is dispensed JH 79 3095 1 Dec 2022 08:51 HPNF (RN Laura McCarthy) Case man 49 Folio 4 0792 HPNF 49 Folio 5g 0957 Previous experience in custody Chronic lower back pain On Methadone program Denies current thoughts of self-harm / harm to others and suicidal ideation Normal cell placement – lower bunk Cleared from quarantine by JH Methadone 140mg is dispensed JH 79 3093 11:35 Review by CNC Tenille McDowell (MHN) JH 78 2993 Reason for referral: Requesting to see MH team for his ?regular mirtazapine. pt reports pt was prescribed mirtazapine whilst in custody -unsure dosage … Pt complaining of recent head injury and main concern re: vision changes. Nil MH symptoms on background of depression hx. Not on mirtazapine for 2 years. Complaining of over sleeping since head injury.
Plan
12:14 Placed in R Block POD 26 cell 788 OIMS housing 52 1096
Date Time Event Ref e 12:49 RN Gurung JH 78 2995 BP 141/78 | HR 62 | SpO2 99 | RR 18 | T36.1 2 Dec 2022 Methadone 140mg is dispensed JH 79 3093 09:38 NP Danielle Peel JH 78 2996 RN attended ECG due to raised blood pressure Says previously on blood pressure medication - stopped taking it - unclear why… Obs: 176/80 161/85 HSDNM ? aortic murmur ECG attended – NAD (static) Equal air entry bilaterally BS x 4 Nil ankle oaedema IMP: to re-commence usual medications Plan: PHN to check BP daily for 2/52 – escalate to GP/NP if elevated
ECG JH 78 2821 POSSIBLE LEFT ATRIAL ENLARGEMENT [-01mV P
WAVE IN V1/V21 LEFT VENTRICULAR HYPERTROPHY AND ST-T CHANGE [VOLT AGE CRITERIA PLUS ST/ ABNORMALITY] PROBABLE INFERIOR MYOCARDIAL INFARCTION [35 ms Q WAVE IN I/aVFl, OF INDETERMINATE
AGE ABNORMAL ECG Medication charted by NP Peel JH 79 3086 Panadol osteo 2 tabs BD Perindopril 5mg mane Rabeprazole 20mg daily Diclofenac PRN 11:51 EN McNamara JH 78 2998 Note re BP review and ECG, reviewed by NP Booked on PAS for follow-up
Date Time Event Ref e 13:30 RN Lucas – ECG attended JH 78 2999 3 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 EN Copeland JH 78 3000 Seen in clinic for BP check – BP 137/75 | HR 67 [Pt] stated systolic normally sits around 170/80 PAS waitlist PAS waitlist 81 Line 10 Primary health - please attend CDS bloods Priority 3 = non-urgent PM Medication panadol, perindopril, rabeprazole JH 79 3086 20:41 EN Ngalob – informed Greg would need to fast JH 78 3001 for blood tests the following morning 4 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 Greg writes to his mother Letter 6 0196 … they have me on Blood Presher Tablets twice daily now and my level is back to 158, I am waiting to see the doctor about my head … I’m waiting for Ross Hill y get in contact with me as I want him to apply for parklea drug programme … I have no money at all that’s why I havnt rang the only time I range was when welfare rang up for me and let me tak to Kerry 13:09 EN Curtain – bloods taken JH 78 3002 Blood tests JH 78 Pathology 3065 Cholesterol 5.2 N <=5.5 Triglycerides 1.3 N <=2.0
HDL 1.4 N >=1.0 LDL 3.2 H (<=3.0) Cholesterol total/cholesterol in HDL 3.7 Non-HDL cholesterol 3.8 (<=4.0)
HB1AC 4.7 N 4.0-6.0 3066 13:44 RN Henry JH 78 3003
Date Time Event Ref e BP check – BP 147/80 | HR 65 PAS waitlist PAS waitlist 81 Line 10 Adult Ambulatory Mental Health – looking for medication fro anxiety/dep. States he was on avanzas before Priorty 3 = non-urgent PM Medication panadol, perindopril, rabeprazole JH 79 3086 diclofenac 5 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 PM Medication panadol, perindopril, rabeprazole JH 79 3086 6 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 Pfizer Comirnaty vaccine (3rd dose) JH 78 2930 Immunisation 70c 1738 13:46 RN Long JH 78 3004 BP check – BP 145/76 | HR 60 PM Medication panadol, perindopril, rabeprazole JH 79 3086 7 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 09:00 RN Maye JH 78 3005 Pt seen in clinic for observation check post recent head injury… PEARL, left eye sensitive to light during review of pupil activity. Pt complaining of pain to behind eye and to brow bone… Pt reports headaches at time, HTN? recently commenced on perindopril 5mg… Education re medications given as pt was receiving DA'd medication but taken them at night instead of mane, pt now aware to keep medications until the next morning.
... placed on GP list for r/v … BP:161/87mmgh, slightly elevated, pt asymptomatic to same ATOR.
Date Time Event Ref e
BP 161/87 PAS waitlist PAS Wait line 7 Primary health - post head injury 15/11/22-ct brain and spine done showing occipital fracture, stilll experiencing dizziness/ lgiht headedness/head aches at times. Sensitive to light in left eye Priority 3 = non-urgent PAS Wait line 6 Primary health - requested by Dr. Grimsdale - HCV positive, ? PCR status, PCR requested Priority 2 = semi-urgent Downing Centre Local Court SIR 49 [30] 0602 Remanded to 18 Jan 2023 Warrant 49 Folio 3(f) 0787 Greg is interviewed by RAPO Belinda Hall OIC 8 [68] Hall 10 0287 OIMS 49 Folio 7b 1048 They discuss Greg becoming Aboriginal Delegate – he was a delegate at Parklea PM Medication panadol, perindopril, rabeprazole JH 79 3086 8 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 10:05 Dr Sasanka Dissanayake JH 78 3007 Dissanayake 35 [11] 0407 Since yesterday, has a sharp headache 9/10 with postural dizziness and pain behind his eye…
BP – 118/71 PEARL, -3mm Shading his eyes Right eye sensitive to light… IMP- ongoing concussive symptoms Dehydration and vaccine related symptoms Plan Ondansetron Encourage oral fluids Review this afternoon - if still unwell, then ED for repeat CT brain Medication charted JH 79 3085 Dissanayake 35 [26] 0409 Ondansetron (Maxolon is dispensed)
Date Time Event Ref e Medical officer/nursing certificate by CNE Clark Certificate 49 Folio 5f 0956 Suffering recent concussive symptoms.
Headache, nausea, exhaustion, dizziness I recommend he has time in cell if feeling unwell/headache/nausea. Allow exercise if feeling well 14:38 RN Long (with Dr Dissanayake) JH 78 3009 Dissanayake 35 {31] 0409 BP 119/65 | HR 98 (am) BP 126/78 | HR 78 (pm) Dr.Sasanka also reviewed at this time and requested for patient to get another antiemmitic and to wait and see if he improves.
Did not want to transfer patient out at this time PM Medication panadol, perindopril, rabeprazole JH 79 3086 20:57 RN Ngalob JH 78 3011 Welfare check 9 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 08:50 RN Fleming JH 78 3013 BP 141/74 | HR 63 | SPO2 78% (sic) Greg is interviewed by RAPO Belinda Hall for the OIC 8 [68] Aboriginal Delegate position, and was successful Hall 7 0287 Bove 31 0312
OIMS 47 PM Medication panadol, perindopril, rabeprazole JH 79 3086 10 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 10:53 RN Mathew JH 78 3014
BP 151/84 | HR 65 | SPO2 97% PM Medication panadol, perindopril, rabeprazole JH 79 3086 11 Dec 2022 AM Medication panadol, perindopril, rabeprazole, JH 79 3086 diclofenac Methadone 140mg is dispensed JH 79 3093 09:17 Greg makes a call to JC (81 seconds) OTS 49 Folio 8h 1073
Date Time Event Ref e Last successful call Greg made 11:57 RN Vora JH 78 3015
BP 145/88 | HR 86 Nil issues raised PM Medication panadol, perindopril, rabeprazole JH 79 3086 12 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 08:40 RN Spriggs JH 78 3016 Patient remains to feel slightly nauseous at time, nil vomiting
BP 154/86 |HR 78 Patient requesting medical cert to remain inside, old cert has expired. Spoke with NUM re same, new cert issued for review in 3/7 Greg has an education assessment session. He is Perry 11 0288 told there is no education program offered at MRRC, although there may be at his gaol of classification PM Medication panadol, perindopril, rabeprazole JH 79 3086 13 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 08:19 RN Maye JH 78 3017 Pt reports headaches and dizziness has improved, still occurs at time. PEARL intact at size 3, left eye remains sensitive to light…
BP 153/81 | HR 66 14:17 RN Maye JH 78 3018 Discussed with GP Dr Hinder, nil requirement to alter antihypertensive at present.
Continue to r/v, escalate if pt continuously elevated in BP.
PM Medication panadol, perindopril, rabeprazole JH 79 3086 14 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086
Date Time Event Ref e Methadone 140mg is dispensed JH 79 3093 10:25 RN Honan JH 78 3019
BP 164/68 | HR 79 PM Medication panadol, perindopril, rabeprazole JH 79 3086 15 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 09:25 RN Maye JH 78 3020 Nil headaches/dizziness or light headedness
Still experiencing same at times, improved as of recent.
PEARL intact at size 3, sensitivity to light remains to left eye, same also improving, nil blurred vison associated with same.
BP 159/69 | HR 77 Pt BP slightly elevated as of recent, as per pt he is more stressed at present, possible cause to elevated BP?. Pt on anti-hypertensive, compliant with taken same. Continue to monitor, if continued to be elevated, escalate to GP Belinda Hall (RAPO) – discussion about a Yarning OIC 8 [68] Circle and an art competition Hall 7 OIMS 49 Folio 7b 1049 12:50 Sandra Anni helps Greg contact Centrelink, to Anni 24 0304 correct the date when he entered custody OIMS 49 Folio 7b 1049 13:26 Placed R block POD 26 cell 784 OIMS housing 52 1096 PM Medication panadol, perindopril, rabeprazole JH 79 3086 16 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 08:07 RN Honan JH 78 3021
BP 162/96 | HR 76 …Reports he is anxious about his elderly mother who has just been released from hospital, reassurance offered. On GP waitlist regarding review of ongoing hypertension, compliant with anti-hypertensives. Nil other issues voiced.
PAS waitlist
Date Time Event Ref e RAPO Belinda Hall speaks to Greg. Greg is asked Hall 10 0287 to speak to other Aboriginal inmates about what they would like to see in the Yarning Circle, and the art competition PM Medication panadol, perindopril, rabeprazole JH 79 3086 17 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 08:49 RN Philip JH 78 3022
BP 152/84 | HR 74 On GP waitlist to be review PM Medication panadol, perindopril, rabeprazole JH 79 3086 18 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 14:20 RN Zhang JH 78 3023
BP 160/87 | HR 68 PAS waitlist PAS Waitlist 81 Line 5 Primary health - Uncontrolled HT, please review medication dose Priority 2 = semi-urgent 19 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 08:32 RN Ziolkowski JH 78 3024
BP 159/82 | HR 77 Pt was alert and orientated ATOR observed ambulating unaided around clinic and speaking in full sentences. Pt reported to be "bit stressed at the moment trying to get all this sorted" Pt on waitlist to be r/v by GP, Pt agreeable to same Nil further concerns or complaints voices during interaction PM Medication panadol, perindopril, rabeprazole JH 79 3086 20 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 08:29 RN Ziolkowski JH 78 3025
Date Time Event Ref e Seen for BP check BP 165/86 | HR 67 | SpO2 98% nil concerns or complaints voiced during interaction 09:48 Dr Dissanayake JH 78 3026 Dissanayake 35 [36] 0410 Discussed with nurse and file review BG of head/facial injury with nasal, orbital floor and left occipital fractures on _______ Was seen in clinic on 8/12 for headache and postural dizziness with dehydration BP at the time was _______ Now has slowly rising HTN (currently on Perindoril 5mg mane) When seen in the clinic today denies any headaches, visual disturbances or lightheadedness or any other symptoms Pt was alert and orientated
BP 165/86 HR 67bpm, Spo2 98%, Temp 35.8, RR 18 Plan Cont thrice weekly BP check for the next 2 weeks If becomes hypertensive (BP > 140/90) then add to GP WL If develops headaches etc then for GP review /discuss with ROAMS GP earlier PM Medication panadol, perindopril, rabeprazole JH 79 3086 21 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 13:51 RN Maye JH 78 3028 Pt seen in clinic for BP r/v, pt post head injury, consistently hypertensive for approx 1/52.
Pt alert and orientated.
Asymptomatic to elevated BP, nil dizziness/ light headedness or blurred vision.
Date Time Event Ref e As per ROAMS GP note 20/12/22 pt for GP waitlist with systolic >140 … BP 166/87 | HR 76 | SpO2 99% Pt admitted to author he has had increased levels of stress at present.
Contributing to elevated BP?
PAS waitlist – GP 3 (non-urgent) PAS Wait line 4 BP >150 consistently for approx 1 week. On prindopril 5mg daily since 2/12/22 PM Medication panadol, perindopril, rabeprazole JH 79 3086 22 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 13:57 RN Long JH 78 3029 Patient seen for BP check due to constant hypertensive episodes. Continues on antihypertensive and awaiting GP review for same.
Patient reports feeling well ATOR, nil headache at this time. Mobilising with nil issues and nil dizziness noted. Observations stable but continues to be hypertensive.
BP 166/85 | HR 70 | SpO2 98% | T 36.2 | RR 17 Patient agreed to knock up if any concerns Appointment booked at St Vincent’s Appoint 65 PAS waitlist PAS Waitlist 81 Line 3 St Vincents Hospital Plastic Clinic F/up Appointment history of Facial injury W/ nasal orbital Floor Discharge 25/11/22 in St VincentsMRN- 07 33423- Tel: 8382 3110 L3 Ambulatory Care Outpatient Priority 5 = follow-up PM Medication panadol, perindopril, rabeprazole JH 79 3086 23 Dec 2022 07:56 RN Harman JH 78 3030 BP 155/86 | HR 74 | SpO2 99% | T 36 | RR 17 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 PAS waitlist PAS Waitlist 81
Date Time Event Ref e Line 2 Primary health - Daily BP until stable Priority 4 = routine 08:00 Completes Health Survival Tips course OIC 8 [72] 0223 Vosalotaki 25 0305 OIMS 49 Folio 7b 1049 PM Medication panadol, perindopril, rabeprazole JH 79 3086 24 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 11:54 RN Yang JH 78 3031 Alert and orientated, appears well. Patient stated that he experienced mild dizziness occasionally, denied headache BP 146/91 | HR 98 | SpO2 96 PM Medication panadol, perindopril, rabeprazole JH 79 3086 26 Dec 2022 AM Medication panadol, perindopril, rabeprazole JH 79 3086 Methadone 140mg is dispensed JH 79 3093 09:27 RN Philip JH 78 3032 BP 134/85 | HR 88 | SpO2 99% | T 35.9 | RR 18 Denies headache, blurred vision and weakness at the time of review PM Medication panadol, perindopril, rabeprazole JH 79 3086 27 Dec 2022 07:54 Methadone 140mg is dispensed SIR 49 [5] 0596
JH 79 3093 AM Medication is not dispensed JH 79 3086 09:20 RN Ian (written on account of RN Ha) JH 78 3035 Ian 34 [6] 0403 BP 1385/80 (sic) | HR 81 | SpO2 96% | T 36.1 Denies headache, blurry vision. Encouraged to knock up if any concern. Appointment booked for tomorrow for same 09:51 Greg attempts to make a call – does not connect OTS 49 Folio 8h 1071 13:07 A fight breaks out in POD 26 Use of force 49 5(l) 0978 CCTV 49 Folio 6bi A group of inmates start fighting (the names of other inmates have been intentionally omitted)
Date Time Event Ref e 13:07 (The name of other inmate has been CCTV 49 Folio 6bi intentionally omitted) arms himself with a vacuum cleaner pole and strikes (the name of other inmate has been intentionally omitted) with it 13:08 Immediate Action Team attends POD 26 OIC 8 [9] OIC 9 image 12 0239
SIR 49 [74] 0609 Incident 49 Folio 5l 0979 Mau 106 [9] 3353 13:08 CO Mau (IAT 5) knocks on window and directs Mau 106 [9] 3353 inmates to stop fighting.
13:08 Use of force - OC spray is deployed by CO Lau Mau 106 [9] 3353 Nau 49 Folio 5l 0987 CCTV 49 Folio 6bi CO Sioata Nau opens the door to the POD, and CO Mau deploys 2 x OC fogger bursts towards inmates (the names of other inmates have been intentionally omitted), and then 1 further burst after entering the POD.
Greg is standing few metres away. Some spray contacts with his face and hand 13:08 IAT enter the POD, followed by other officers CCTV 49 Folio 6bi CO Mau shouts “Move, move back, get back to BWV 49 6(p) your fucking cells, move, move back, get in your fucking cell” 13:08 Greg returns to his cell (c. 4 seconds after OC SIR 49 [7] spray is deployed) CCTV 49 Folio 6bi 13:09 POD 26 is placed into lock down 13:09 CO Satnam Singh looks into Greg’s cell, and OIC 9 p17 0244 checks he is present, and shuts the door. Singh 105 [6] 3348 Hewson 15 0293 Hewson 107 [7] 3375 He does not have a key to lock the cell, so asks CCTV 49 Folio 6bi FM Hewson to lock it 13:09 Greg’s cell is locked by FM Daniel Hewson CCTV 49 Folio 6bi 13:10 Multiple other officers enter the POD CCTV 49 Folio 6bi 13:11 IAT secure detain inmates in the yard CCTV 49 Folio 6bi 13:12 (The name of other inmate has been CCTV 49 Folio 6bi intentionally omitted) is led back into the POD in handcuffs 13:15 (The name of other inmate has been CCTV 49 Folio 6bi intentionally omitted) is taken away ? for a medical check
Date Time Event Ref e 13:15 CO Meznaric goes to cell 784, opens the hatch Meznaric 109 [9] 3382 and looks inside briefly. CO Meznaric believes he CCTV 49 Folio 6bi CCTV 49 Folio 6d saw Greg “pacing and standing in the cell” Last confirmed sighting of Greg alive 13:18 IAT and others leave the POD CCTV 49 Folio 6bi No-one enters the POD from 13:18 to 13:38 CCTV 49 Folio 6bi u/k FM MacFarlane asks FM Dorrans to go to each McFarlane 104 [6] 3346 cell, to see if inmates were affected by gas u/k FM Dorrans and other officers go to POD office Dorrans 99 [9] 3256 for a debrief. He checks the muster book to identify who was involved FM Dorrans may have called the clinic, to ask for nurses to attend to do a welfare check u/k CO Pradap receives a call from an unknown Pratap 100 [6] 3259 officer in the clinic, saying an incident had occurred, gas had been used, and JH nurses needed to attend to do a welfare check 13:00 CO Pratap asks nurse to do a welfare check on Ian 34 [8] 0404 inmates in R POD, as gas had been used 13:15 RN Ian and RN Harman arrive in POD office. Ian 34 [9] 0404 POD 26 officers say the cells are not to be Pradap 100 [14] 3259 opened alone (only the hatches) RN Harman asks NUM to arrange additional staff. RN Ian goes to M Block clinic and returns with RN Ha 13:26 A nurse (? RN Ian) can be seen in the POD office CCTV 49 Folio 6bi 13:38 CO Pratap, with RN Harman, RN Ha and RN Ian OIC 9 p21 0248 enter POD 26 to conduct welfare checks. They SIR 49 [10] Ian 34 [10] 0404 commence on LHS of ground floor 13:40 RN Ian goes upstairs to check top level cells CCTV 49 Folio 6bi 13:40 RN Harman attends cell 784. OIC 9 p22 0249
SIR 49 [80] Pradap 100 [9] 3259 She observes Greg unresponsive in shower area.
CCTV 49 Folio 6bi She says “man down” CCTV 49 Folio 6d About 31 minutes after cell was locked 13:41 CO Pratap and RN Ha attend cell 784 OIC 9 p24 0251 Pradap 100 [10] 3259
Date Time Event Ref e 13:41 CO Pratap goes to POD office and speaks to FM Pradap 100 [10] 3259 Dorrans CCTV 49 Folio 6bi 13:41 RN Ian leaves the POD, and then attend returns JH 78 (Ian) 3033 with FM Dorrans and others CCTV 49 Folio 6bi 13:42 FM Dorrans enters POD and goes to cell 784. Dorrans 18 0298 Dorrans 99 [13] 3256 CCTV 49 Folio 6bi He sees Greg crouched in the shower. He calls out to Greg but gets no response. He then opens the cell door 13:42 Greg’s cell is opened by FM Dorrans OIC 9 p26 0253
SIR 49 [9] About 30 seconds after FM Dorrans arrives 13:43 NUM Gonzalez calls ambulance JH 78 3036 Greg is moved from cell to corridor by Dorrans Dorrans 18 0298 and Pratap RN Dwyer attends with crash cart JH 78 (Dwyer) 3034 u/k Meznaric commences using handheld camera, Meznaric 12 0290 which is not working 13:44 CPR is commenced by FM Dorrans Dorrans 18 0298 13:45 CO Robinson attends and records list of names Robinson 19 0299 13:47 Meznaric obtains a new camera and starts Meznaric 12 0290 recording events 14:05 Paramedics attend SIR 49 [54] 0605 14:30 CPR ceased 14:30 Time of death Verification 1 0001 14:33 Police broadcast OIC 8 [27] 0208
CONFRIMED DECD OF A MALE 14:36 Cell secured 14:30 Police (Brown) attend P79A 1 p7 A round orange tablet is found in Greg’s pocket, P79A 1 p7 0211 within similar tablets and other drugs located in OIC 8 [38] resealable bags in the cell Bags with the names (the names of other inmates have been intentionally omitted) also found in the cell 18:40 After action review conducted in IAT office Review 17 0296 19:20
Date Time Event Ref e Dorran, Meznaric, Pratap, Biala, Robinson, Warwick, Hristov, McFarlane, Hewson, Joseph, Brown are present All staff were given an opportunity to present actions and thoughts about the death 19:11 Cell call alarm test OIC 8 [44]
SIR 49 [81] 0616 No other calls had been made from the cell DIR 49 Folio 8g 1069 22:00 OIC contacts Kerry-Anne OIC 8 [48] 0213 29 Dec 2022 Use of Force Review Use of force 40i OIC speaks with Shannon OIC 8 [52] 0214 30 Dec 2022 Autopsy (Dr Elsie Burger) PM 3 0011 Direct cause: Acute myocardial infarction Antecedent causes: Ischaemic heart disease BMI 27.3 kg/m2 (85.5kg) Concentration of methadone in the reported lethal range. However, tolerance can develop with prolonged use.
COVID-19 infection is associated with increased risk of MI, even months after infection.
No obvious signs of acute infection 13:45 Alcohol wipes of Gregs hands and face EFIMS 47 0554 – these later reveal OC spray Neuropathology (A/Prof Buckland)
Moderate small vessel disease…
Remote likely haemorrhagic infarcts…
No acute pathology Toxicology Tox 3 0040 Alcohol ND Aripiprazole <0.05mg/L Not prescribed Mirtazapine 0.10mg/L Not prescribed Methadone 1.3mg/L Perindopril was not assayed Virology PM 3E 0044 Sars-CoV-2 RNA DETECTED
Date Time Event Ref e Chemical analysis Chemical 4 0049 Components of OC spray are detected on wipe samples from face and left hand 5 Jan 2023 Planned appointment at St Vincent’s plastics JH 79 3097 18 Jan 2024 Downing Centre Local Court - next court date OIC 8 [3] 0203
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