Inquest into the death of Francis Michael Fahey

CORONERS COURT OF QUEENSLAND FINDINGS OF INQUEST CITATION: Inquest into the death of Francis Michael Fahey TITLE OF COURT: Coroners Court

JURISDICTION: BRISBANE FILE NO(s): 2023/1869 DELIVERED ON: 14 April 2026

DELIVERED AT: BRISBANE HEARING DATE(s): 14 April 2026 FINDINGS OF: Terry Ryan, State Coroner CATCHWORDS: Coroners: inquest, natural causes, death in custody, metastatic melanoma.

REPRESENTATION: Counsel Assisting: Ms D Palmer Metro North Health Ms N Mason Queensland Corrective Services Mr L O’Connor

Contents

Introduction

1. Francis Michael Fahey was seventy years of age when he died at the Royal Brisbane and Women’s Hospital (RBWH) on 18 April 2023. Mr Fahey was serving a lengthy term of imprisonment for two counts of murder. He was transferred from the Woodford Correctional Centre (WCC) to the RBWH for treatment following an inability to mobilise independently and shortness of breath. Mr Fahey had been diagnosed with metastatic melanoma in March 2023.

Mr Fahey died of natural causes as a result of metastatic cancer with ischaemic heart disease also considered to have contributed to his death.

Coronial jurisdiction

2. At the time of his death, Mr Fahey was a prisoner in custody as defined in Schedule 4 of the Corrective Services Act 2006 (Qld). Mr Fahey’s passing is a reportable death under section 8(3)(g) of the Coroners Act 2003 (Qld) (the Act) as it is a ‘death in custody’.

3. In cases such as this, an inquest is mandatory pursuant to s27(1)(a)(i) of the Act.

An inquest is intended to provide the public and, most importantly, the family of the deceased, with transparency regarding the circumstances of the death, and to answer any questions which may have been raised following the death.

4. The role of the coroner is to independently investigate reportable deaths to establish, if possible, the identity of the deceased, the medical cause of death, and the circumstances surrounding the death – how the person died. Those circumstances are limited to events which are sufficiently connected to the death.

The purpose of a coronial investigation is to establish the facts, not to cast blame or determine criminal or civil liability. Those are matters for other courts.

5. The relevant standard of proof is that of the balance of probabilities, with reference to the Briginshaw1 standard. Accordingly, the more significant the issue for determination, the clearer and more persuasive the evidence must be for the coroner to be sufficiently satisfied on the balance of probabilities that the issue has been proven: But reasonable satisfaction is not a state of mind that is attained or established independently of the nature and consequence of the fact or facts to be proved. The seriousness of an allegation made, the inherent unlikelihood of an occurrence of a given description, or the gravity of the consequences flowing from a particular finding are considerations which must affect the answer…In such matters ‘reasonable satisfaction’ should not be produced by inexact proofs, indefinite testimony, or indirect inferences.2 1 Briginshaw v Briginshaw (138) 60 CLR 336.

2 Briginshaw v Briginshaw (138) 60 CLR 336, 362 – 363 (Dixon J).

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The investigation

6. The investigation into Mr Fahey’s death was led by Detective Senior Constable (DSC) Sym Khaile of the Queensland Police Service (QPS) Corrective Services Investigation Unit (CSIU).

7. After being notified of Mr Fahey’s death on 18 April 2023, Detectives Khaile and Flintham from the QPS CSIU attended bed 33 in Ward 7A at the RBWH.

DSC Khaile observed Mr Fahey lying on his back on the hospital bed and covered in hospital sheets and blankets. No medical equipment was attached to Mr Fahey and no signs of trauma or any indications of a suspicious death were observed. Mr Fahey was formally identified by Correctional Supervisor, Christopher Oakey, who had known Mr Fahey for several years.

8. On 19 April 2022, I made a direction for a targeted police investigation to occur.

A Coronial Investigation Report was prepared and provided to the Coroners Court in August 2023.

9. DSC Khaile conducted a thorough investigation in response to the targeted direction. She concluded that there were no suspicious circumstances in relation to Mr Fahey’s death and that he was provided with adequate medical care while incarcerated.

The inquest

10. The inquest was held at Brisbane on 14 April 2026. All statements, medical records and materials gathered during the investigation were admitted into evidence. No witnesses were called to give oral evidence. Counsel Assisting proceeded to submissions on the investigation material in lieu of any oral evidence.

11. The issues considered at the inquest were the issues required by s 45(2) of the Act, and whether Mr Fahey had access to, and received appropriate medical care, while he was in custody.

12. I am satisfied that all material necessary to make the requisite findings was placed before me at the inquest.

The evidence Social and Medical History

13. Mr Fahey was born on 15 February 1953 in Brisbane, where he grew up with his brother, Peter, initially at Annerley and later at Camp Hill. Mr Fahey was twice married with three adult children from his first marriage.

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14. Mr Fahey and Peter both volunteered in the St John Ambulance brigade.3 Mr Fahey worked as a mechanic before joining the Queensland Ambulance Service.4 Peter described Mr Fahey as being “a very healthy person”, however, noted that he smoked, drank and did not exercise.5

15. Mr Fahey’s criminal history was short but significant. On 7 May 2003, Mr Fahey was arrested in relation to two counts of murder which were committed on or about 8 August 2002 and on or about 26 February 2003.6 Mr Fahey was initially held on remand at Arthur Gorrie Correctional Centre between 8 May 2003 and 19 May 2003 before he was transferred to Wolston Correctional Centre.7

16. On 11 April 2006, Mr Fahey was sentenced in the Supreme Court at Brisbane to life imprisonment and was not eligible for post-prison community-based release for a period of 25 years.8 His parole eligibility date was set at 5 May 2028.9

17. On 12 July 2016, Mr Fahey was transferred to Woodford Correctional Centre where he remained in custody until his death on 18 April 2023.10

18. Mr Fahey’s medical history included insulin dependent Type 2 Diabetes Mellitus, Ischaemic Heart Disease, Depression/Anxiety, Dyslipidaemia, Hypertension and a previous advanced Zygoma Cutaneous Squamous Cell Carcinoma.11

19. Mr Fahey was prescribed several medications while in custody at Woodford Correctional Centre including:12 a. Insulin Glargine (38 units at dinner) b. Gliclazide MR (60mg Mane) c. Atenolol (50mg Mane) d. Metformin XR (2g Mane) e. Ezetimibe (10mg Nocte) f. Dapagliflozin (10mg Mane) g. Perindopril (5mg Mane) h. Mirtazapine (30mg Nocte) i. Isosorbide Mononitrate XR (120mg Mane) j. Venlafaxine XR (150mg Mane) k. Atorvastatin (80mg Mane) l. Aspirin (100mg Mane) m. Macrogol 3350 (2 sachets BD) n. Tapentadol XR (50mg BD) o. Paracetamol (PRN) p. Ibuprofen (PRN) 3 Ex B2 – Statement of Peter Fahey at [4].

4 Ex B2 – Statement of Peter Fahey at [7].

5 Ex B2 – Statement of Peter Fahey at [6].

6 Ex A4 – Coronial Report, page 3.

7 Ex A4 – Coronial Report, page 3.

8 Ex C1 – Criminal History.

9 Ex A4 – Coronial Report, page 4.

10 Ex A4 – Coronial Report, page 4.

11 Ex E2 – Clinical Incident Review by Dr Chng, page 3.

12 Ex E2 – Clinical Incident Review by Dr Chng, pages 3 – 4.

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q. Oxycodone (5mg as a PRN single dose to aid his pain for transfer to hospital)

20. The movement history received from Queensland Corrective Services, dating back to July 2021, showed that Mr Fahey was transported to the Princess Alexandra Hospital (PAH) Secure Unit (SU), Caboolture Hospital and RBWH on multiple occasions to receive medical treatment.13 Care in custody Previous diagnosis and treatment of advanced right zygoma cutaneous squamous cell carcinoma

21. On 24 June 2020, Mr Fahey submitted a Health Services Request to see a doctor in relation to a “skin cancer wound on face.”14 A week later he underwent a medical review and was referred for a biopsy.15 The histopathology from the biopsy revealed the lesion was a squamous cell carcinoma.16

22. On 12 August 2020, Mr Fahey was seen as an outpatient in the PAH Plastic Surgery Department and reported that the lesion had been present for some months after he initially nicked it when shaving and it then increased in size.17

23. In December 2020, an MRI of his skull base showed a large, ulcerated lesion on his right cheek extending to the zygomatic arch. This was confirmed in a PETCT scan that month, with no identified distant metastatic disease.18 A further MRI of his skull base in February 2021 showed a progressive increase in the size of the lesion and on 19 February 2021, Mr Fahey underwent a right zygomatic squamous cell carcinoma resection with free flap.

24. In March 2021, Mr Fahey was treated for infection of the left thigh donor site at the PAH.19 Treatment included intravenous antibiotics20 and the application of betadine paint to the sites.21 In April 2021, Mr Fahey was also treated for an infection to his facial skin graft site.

25. On 3 June 2021, Mr Fahey attended an appointment at the PAH with Consultant Radiology Oncologist, Dr Lui, who spoke to Mr Fahey in relation to undergoing six weeks of post-operative radiotherapy and outlined the potential side effects.

However, Mr Fahey declined to undergo radiotherapy due to the time it would take to travel to the PAH from Woodford Correctional Centre.22 In declining 13 Ex D2 – Movement History.

14 Ex E8 – FAHEY, Francis PHS IM Vol 3, page 76.

15 Ex E8 – FAHEY, Francis PHS IM Vol 3, page 9.

16 Ex E8 – FAHEY, Francis PHS IM Vol 3, page 11.

17 Ex E8 – FAHEY, Francis PHS IM Vol 3, page 169.

18 Ex E6 - PAH records, page 619.

19 Ex E6 - PAH records, pages 199, 204.

20 Ex E6 - PAH records, page 203.

21 Ex E6 - PAH records, pages 193, 203.

22 Ex E6 - PAH records, page 355.

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treatment, Dr Lui had counselled Mr Fahey in relation to the risks associated with refusal.23

26. Mr Fahey continued to attend PAH outpatient appointments to monitor his recovery and in September 2021, an MRI of his skull base showed there was no sign of recurrence at that time.24

27. In August 2022, Mr Fahey reported during a telehealth review appointment that “he was not experiencing pain, had no new neck lumps and no unintentional weight loss”.25 An MRI on 2 November 2022 also showed no sign of recurrence.26 Diagnosis of metastatic melanoma

28. On 23 February 2023, Mr Fahey submitted a Health Services Request seeking medical review of a sudden onset lump under his right armpit.27 He was triaged as a Category 1 and was examined by Dr Chng that morning who noted that Mr Fahey reported a two-day history rapid onset of the lump.28

29. The firm lump measured 10cm in diameter, was non-fluctuant and tender.29 Dr Chng considered a differential diagnosis of lymph node malignancy or infection and transferred Mr Fahey to the Caboolture Hospital Emergency Department, to undergo a CT scan with oncology input.30

30. Mr Fahey was reviewed at the Caboolture Hospital Emergency Department where an ultrasound identified multiple enlarged lymph nodes in his right armpit, the largest of which measured 47x31x46mm.31 It was noted “adjacent largest neck, there are 3 morphologically similar nodes measuring 18, 10 and 11mm” which were “highly suspicious in appearance.”32 It was recommended, noting Mr Fahey’s history of squamous cell carcinoma, that he undergo further scans and a biopsy of the largest lymph node.33 Mr Fahey was discharged from Caboolture Hospital back to Woodford Correctional Centre.34

31. On 25 February 2023, Mr Fahey was referred for an urgent CT scan of his chest/abdomen/pelvis and soft tissues of neck35 and a biopsy.36 On that day Mr Fahey was also treated in relation to a left upper leg infection.37 23 Ex B5 - Statement of Dr Howard Liu, at [23].

24 Ex E6 - PAH records, page 335.

25 Ex E6 - PAH records, page 361.

26 Ex E6 - PAH records, page 359; Ex E6 – Caboolture Hospital Records, page 136.

27 Ex E5 – PHS records 1, page 53.

28 Ex E5 – PHS records 1, page 15.

29 Ex E5 – PHS records 1, page 15.

30 Ex E5 – PHS records 1, page 15.

31 Ex E3 – Caboolture Hospital records, page 36.

32 Ex E3 – Caboolture Hospital records, page 36.

33 Ex E3 – Caboolture Hospital records, page 36.

34 Ex E3 – Caboolture Hospital records, pages 37, 73.

35 Ex E3 – Caboolture Hospital records, page 162; Ex E2 – Clinical Incident Review, Dr Chng, page 2.

36 Ex E2 – Clinical Incident Review by Dr Chng, page 2.

37 Ex E2 – Clinical Incident Review by Dr Chng, page 2.

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32. On 8 March 2023, Mr Fahey was reviewed by Dr Chng who noted that Mr Fahey still had an infection and was commenced on a two-week course of tramadol XR 50mg pending tissue diagnosis, which was considered likely to be a metastatic malignancy.38

33. On 14 March 2023, Mr Fahey underwent a CT scan at the Caboolture Hospital which showed a large mass in his right armpit at the level of his 1st – 3rd ribs and extended along the right side of his chest.39 It was concluded that “overall features are suggest of metastases or a lymphoproliferative disorder” and a recommendation was made for Mr Fahey to undergo urgent further evaluation, specialist review and a core biopsy.40

34. On 17 March 2023, Mr Fahey underwent an ultrasound core biopsy of his right axillary mass which confirmed that “the appearance and immunohistochemical profile are consistent with metastatic melanoma”.41

35. On 31 March 2023, Mr Fahey had an outpatient PET/CT scan at the RBWH which showed:42

• Widespread FDG avid metastatic disease, with nodal, skeletal, soft tissue, pleural, left adrenal, and peritoneal metastases. Possible small bowel and gastric metastases.

• Nondisplaced pathological transcervical/subcapital fracture of the left femoral neck, which is new when compared to the diagnostic CT performed 14/03/2023. Further nondisplaced pathological fracture of the left 12th posterior rib.

36. On 1 April 2023, Mr Fahey was admitted to the RBWH under General Medicine for treatment of his fractured left neck of femur following the diagnosis of metastatic melanoma.43 It was noted that Mr Fahey had experienced left hip and leg pain two weeks prior, which had been controlled with pain medication.44

37. It was initially unclear if Mr Fahey was suitable for operative management as the left neck of femur fracture was complicated by the cellulitis of the overlying skin graft on his left thigh.45 In the interim Mr Fahey was commenced on IV antibiotics pending further review.46

38. That afternoon, Mr Fahey’s diagnosis was explained to him during a medical review, at which time it was noted that both of his legs and right hand were swollen. Mr Fahey reported that his legs had started swelling one day prior and his hand three days earlier.47 38 Ex E2 – Clinical Incident Review by Dr Chng, page 2.

39 Ex E1 – RBWH records, page 32; Ex E2 – Clinical Incident Review by Dr Chng, page 2.

40 Ex E1 – RBWH records, page 32.

41 Ex E3 – Caboolture Hospital records, page 103.

42 Ex E1 – RBWH records, page 364.

43 Ex E1 – RBWH records, page 98.

44 Ex E1 – RBWH records, page 99.

45 Ex E1 – RBWH records, pages 100, 102.

46 Ex E1 – RBWH records, page 100.

47 Ex E1 – RBWH records, page 103.

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39. On 2 April 2023, during a medical ward round, and following discussions with Medical Oncology, it was determined that the available options for systemic therapy were dependant on the outcome of BRAF testing of the metastatic melanoma.48

40. A Medical Oncology review initially expected his prognosis to be years with treatment, however this was dependent on his tolerability and response to immunotherapy.49

41. On 3 April 2023, Mr Fahey underwent a partial left hip replacement50 and was able to mobilise the following day during a physiotherapy appointment.51

42. On 5 April 2023, Mr Fahey was reviewed by Medical Oncology during which he was offered a number of treatment options for his metastatic melanoma, including immunotherapy, BRAF targeted therapy, radiotherapy or supportive care only.

Each treatment option was explained, and Mr Fahey chose to undergo six-weekly immunotherapy.52

43. The following day, an echocardiogram showed Mr Fahey had ischaemic cardiomyopathy with mild-moderate Left Ventricular impairment and Ejection Fraction of 40 – 45%.53 Mr Fahey was already taking cardiac medication, and it was recommended that his heart medication be adjusted “in the context of oncology advice around trial of immunotherapy and potential response to treatment/life expectancy.”54 That day Mr Fahey had his first immunotherapy dose without incident.55

44. On 7 April 2023, Mr Fahey was discharged back to Woodford Correctional Centre56 where he appeared frail and struggled transferring from his wheelchair.57 Mr Fahey was advised to tell staff if he had “any concerns, symptoms or deterioration.”58

45. On 10 April 2023, Mr Fahey attended the WCC medical centre for his morning medication, requested additional pain medication, and was unable to weight bear or mobilise independently. He was experiencing shortness of breath and had “bilateral pitting oedema with oozing calf”. Mr Fahey was transferred to Caboolture Hospital by the Queensland Ambulance Service.59 48 Ex E1 – RBWH records, page 106.

49 Ex E1 – RBWH records, page 111.

50 Ex B4 – Statement of Dr John Roe at [10b].

51 Ex E1 – RBWH records, page 122.

52 Ex E1 – RBWH records, pages 129, 148.

53 Ex B1 – Statement of Dr Alison Cutler, page 2; Ex E1 – RBWH records, page 132.

54 Ex B1 – Statement of Dr Alison Cutler, page 2; Ex E1 – RBWH records, pages 132 - 134.

55 Ex B1 – Statement of Dr Alison Cutler, page 2; Ex E1 – RBWH records, pages 134 – 135, 140.

56 Ex E1 – RBWH records, pages 139.

57 Ex E5 – PHS records, page 23.

58 Ex E5 – PHS records, pages 23 – 24.

59 Ex E5 – PHS records, page 24.

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46. On examination it was noted that Mr Fahey’s surgical wound was clean, and he had bilateral pitting oedema in both lower legs up to the knee.60 He was also taking antibiotics for sepsis of unknown origin.61

47. On 13 April 2023, Mr Fahey was transferred and admitted to the RBWH.

48. On 15 April 2023, Mr Fahey reported difficulty breathing and shortness of breath.

He did not report chest pain but described his abdomen as feeling heavy, and that he had not had a bowel movement in approximately a week.62 By the afternoon his shortness of breath had improved.63

49. The following day, Mr Fahey was reviewed in relation to an increased respiratory rate and decreased blood pressure, and he reported shortness of breath on exertion but not at rest. He had bilateral crackling in his lungs and was recommended to have a chest x-ray.64

50. During a cardiology review that morning, his surgical wound infection concerns were noted as were his significant fluid overload with non-compliance with fluid retention. It was recommended that his fluid be controlled.65

51. On 17 April 2023, it was recommended that Mr Fahey undergo a CT scan of his chest and a chest x-ray to assess his progress, however, this did not go ahead as a CT scan from six days prior showed “nodal bleeding and established pleural effusion.”66

52. Mr Fahey was counselled in relation to his options following a deterioration of his health and he elected for comfort cares to be given.67 Mr Fahey was to be referred to Palliative Care the following day,68 and he was commenced on a subcutaneous infusion of hydromorphone, midazolam and haloperidol.69

53. Mr Fahey completed an Acute Resuscitation Plan in which he requested that he be provided with comfort cares only. He indicated that he did not want CPR, ICC, intubation or a defibrillator to be used.70

54. That evening Mr Fahey’s brother visited him and observed that his health had deteriorated since he last saw him, and that he appeared to be in a lot of pain.71 60 Ex E3 – Caboolture Hospital records, page 5.

61 Ex E3 – Caboolture Hospital records, page 8.

62 Ex E1 – RBWH records, page 71.

63 Ex E1 – RBWH records, page 75.

64 Ex E1 – RBWH records, pages 76 – 77.

65 Ex E1 – RBWH records, page 78.

66 Ex E1 – RBWH records, pages 90, 93.

67 Ex B1 – Statement of Dr Alison Cutler, page 3.

68 Ex E1 – RBWH records, page 94.

69 Ex B1 – Statement of Dr Alison Cutler, page 3; Ex E1 – RBWH records, page 94.

70 Ex E1 – RBWH records, page 2.

71 Ex B2 – Statement of Peter Fahey at [20].

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55. At approximately 1:23am, the early hours of 18 April 2023, Mr Fahey was observed by Correctional Officer Cameron Fowler as he breathed. Approximately two minutes later CCO Fowler saw that Mr Fahey had stopped braking and did not respond to voice.72 A nurse was called who confirmed his heart rate could not be found.73

56. Mr Fahey was declared deceased at 2:44am by Dr Zala Skrbis.74 Forensic Medicine Queensland advice

57. Given Mr Fahey’s previous diagnosis and treatment of an advanced right zygoma cutaneous squamous cell carcinoma, I sought advice from Forensic Medicine Queensland as to the adequacy of the medical treatment provided to Mr Fahey while in custody, particularly relating to the management of his cancer.

58. On 17 October 2025, Forensic Physician, Dr Mitchell Shaw provided an advice in which he noted that Mr Fahey’s squamous cell carcinoma75 had showed no evidence of metastatic spread and no recurrence had been identified in MRI scans.76 Dr Shaw did note, however, that:77 Given Mr Fahey developed a significant skin cancer, he should have been considered at risk of further skin cancers. Despite skin checks being a common practice in Australia as primary prevention and for secondary prevention (after a skin cancer has been diagnosed) this is not a formally endorsed preventative health strategy in primary care.

59. In concluding that Mr Fahey’s melanoma was not obviously preventable and was not related to his previous diagnosis of squamous cell carcinoma, Dr Shaw stated:78 Mr Fahey died of metastatic melanoma, without an established history of primary melanoma. The metastatic melanoma was completely unrelated to the previous diagnosis of squamous cell carcinoma as these cancers are cytologically distinct.

While there appears to have been some issues with the diagnosis and treatment of the past squamous cell carcinoma, this in no way hastened or contributed to the death of Mr Fahey.

Mr Fahey was diagnosed with terminal metastatic disease two days after the development of symptoms and was worked up within a reasonable time frame. Had Mr Fahey been worked up more quickly, this would have in no way altered the outcome.

72 Ex B3 – Statement of Cameron Fowler at [8].

73 Ex B3 – Statement of Cameron Fowler at [8] – [10].

74 Ex B3 – Statement of Cameron Fowler at [14]; Ex E1 – RBWH Records, page 237.

75 FMQ advice of Dr Mitchell Shaw, at [9].

76 FMQ advice of Dr Mitchell Shaw, at [9].

77 FMQ advice of Dr Mitchell Shaw, at [11].

78 FMQ advice of Dr Mitchell Shaw, at [21] – [25].

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The medical records reviewed, particularly in relation to the diagnosis of metastatic melanoma, did not identify any opportunities for outcome changing care.

The Melanoma Institute of Australia’s current position is that there is no strong evidence of benefit to regular skin checks and some potential harms. There was no mention of a primary melanoma lesion in the records reviewed. The combination of these two facts mean that there was no obvious preventability to Mr Fahey’s melanoma.

60. I accept the advice of Dr Shaw.

Autopsy results

61. On 24 April 2023, Forensic Pathologist, Dr Nathan Milne, conducted a preliminary examination consisting of an examination of the body, review of information, blood taken, CT scan, photography and medical summary.79

62. Dr Milne noted that the Post-Mortem CT scan showed “widespread subcutaneous oedema; pleural effusions and ascites; previous [right] facial surgery; large [right] chest wall mass; aortic, coronary and peripheral vascular calcification; [left] hip replacement.”80

63. It was concluded that Mr Fahey had “long standing ischaemic heart disease with heart failure” and had a “very advanced metastatic melanoma including large chest wall mass.”81

64. Dr Milne concluded that the cause of death was 1(a) metastatic melanoma with (2) ischaemic heart disease listed as a significant condition.82 I accept the opinion of Dr Milne.

Conclusions

65. I am satisfied that Mr Fahey died from natural causes. I conclude that none of the inmates, correctional or health care staff at the PAH, Caboolture Hospital or RBWH or Woodford Correctional Centre caused or contributed to his death.

There were no suspicious circumstances.

66. It is an accepted principle that the health care provided to prisoners should not be of a lesser standard than that provided to other members of the community. The evidence tendered at the inquest established the adequacy of the health care provided to Mr Fahey when measured against this benchmark.

79 Ex A3 – Preliminary Examination Report.

80 Ex A3 – Preliminary Examination Report.

81 Ex A3 – Preliminary Examination Report.

82 Ex A2 – Form 30A.

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Findings required by s. 45

67. I am required to find, as far as possible, the medical cause of death, who the deceased person was and when, where and how he came to his death. After considering all the evidence, including the material contained in the exhibits, I am able to make the following findings:

(a) Who the deceased person is: Francis Michael Fahey (DOB: 15 February 1953)

(b) How the person died: Mr Fahey had been imprisoned since 2003. On 23 February 2023, Mr Fahey reported a sudden onset 10cm firm lump under his right armpit. An ultrasound core biopsy of his right axillary mass confirmed a diagnosis of a metastatic melanoma.

Mr Fahey elected to be treated with immunotherapy. However, his condition deteriorated, and he was ultimately transferred to the Royal Brisbane and Women’s Hospital on 13 April 2023 and died in the early hours of 18 April 2023.

(c) When the person died: 18 April 2023.

(d) Where the person died: Royal Brisbane and Women’s Hospital.

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Comments and recommendations

68. Section 46 of the Act enables a coroner to comment on anything connected with a death that relates to public health or safety, the administration of justice or ways to prevent deaths from happening in similar circumstances in the future.

69. On 29 April 2023, Visiting Medical Officer and Senior Medical Officer at WCC, Dr Chng, completed a Clinical Incident Review in relation to the care provided to Mr Fahey whilst in custody. Dr Chng raised following concerns in the review: a. That “a consideration of the logistical difficulties in organising further investigations (security/appointments available) could be made when an incarcerated patient presents to hospital”. Specifically, Dr Chng’s concern was that whilst a CT scan was not performed during Mr Fahey’s initial presentation to the Caboolture Hospital Emergency Department, an appointment was also not made immediately; and b. That “the practice of not communicating via correspondence/letter could certainly impact on the care of patients incarcerated at Woodford.” Dr Chng’s preference was that a letter be sent to the correctional facility by the relevant outpatient speciality unit, in addition to outpatient notes. It was noted that this particular concern did not have any direct impact on Mr Fahey’s prognosis.

70. Dr Chng made the following recommendations: Recommendation 1: PAH ENT and oncology to please review processes in communicating with correctional facilities with letters i.e. equivalent to the communication with a GP in the community would receive.

Recommendation 2: Education of staff at emergency re: difficulty organising investigations from a prison.

71. On 8 April 2026, Acting Nursing Director at Acting Nursing Director, Caboolture Hospital Emergency Department, Kilcoy Hospital and Woodford Prison Health, Mr Paul Kemp, advised that both recommendations made by Dr Chng had been actioned by Metro North Health, with the following processes now implemented: a. Following a review of PAH ENT and Oncology services communication processes, correctional facilities are now provided with “written correspondence following outpatient department appointments that is consistent with the standard ordinarily provided to a patient’s general practitioner”; and b. Caboolture Hospital Emergency Department staff have since received education regarding “the logistical and operational challenges involved in arranging investigations for patients in custody.” Findings of the inquest into the death of Francis Michael Fahey Page 14 of 15

72. Having regard to the implemented recommendations made by Dr Chng in the Clinical Incident Review, I accept that there are no additional comments or recommendations to be made that would assist in preventing similar deaths in the future, or that otherwise relate to public health or safety or the administration of justice.

73. I extend my condolences to Mr Fahey’s family and friends.

74. I close the inquest.

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