Inquest into the Death of Lex Gregory MAHER

[2025] WACOR 12 (S) JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : ROBYN HARTLEY, CORONER HEARD : 10 DECEMBER 2024 DELIVERED : 18 MARCH 2025 FILE NO/S : CORC 119 of 2022

DECEASED : MAHER, LEX GREGORY Catchwords: Nil Legislation: Nil Counsel Appearing: Sergeant C Martin assisted the Coroner.

Mr J Kirke (SSO) appeared on behalf of the Department of Justice.

Case(s) referred to in decision(s): Nil

[2025] WACOR 12 (S) Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Robyn Mary Hartley, Coroner, having investigated the death of Lex Gregory MAHER with an inquest held at Perth Coroners Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 10 December 2024, find that the identity of the deceased person was Lex Gregory MAHER and that death occurred on 27 December 2022 at Greenough Regional Prison, Edward Road, Narngulu, from atherosclerotic heart disease in the following circumstances: Contents

[2025] WACOR 12 (S) INTRODUCTION Lex Gregory Maher was a 45 year old Aboriginal man who died on 27 December 2022 after collapsing on the basketball court at Greenough Regional Prison (GRP).

Due to a series of routine electrocardiograms (ECGs) conducted while Mr Maher was serving a four-year term of imprisonment at GRP, an abnormal result was picked up by a prison medical officer during a medical review in May 2022. Mr Maher was referred to a cardiologist on a semi-urgent basis and an appointment was made for late July 2022.

As a result of an unexplained rescheduling of the July appointment to September that year, followed by Mr Maher being released to freedom in August 2022, he did not end up being reviewed by a cardiologist as planned.

When Mr Maher returned to custody in October 2022, steps were taken to establish whether he had attended a cardiologist while in the community.

When it was determined that Mr Maher was yet to have a cardiology review, he was again referred for a specialist appointment. Sadly, Mr Maher died before arrangements could be made for him to be seen by a cardiologist.

As Mr Maher was a serving prisoner at the time of his death, he was a ‘person held in care’ as defined in the Coroners Act 1996 (WA) (the Act).1 The Department of Justice (the Department) is the state government agency responsible for the care of prisoners.

Any death of a person held in care must be the subject of an inquest.2 The Act requires that a Coroner who conducts an inquest into the death of a person held in care must comment on the quality of the supervision, treatment and care of the person while in that care.3 1 Section 3 Coroners Act 1996 (WA).

2 Section 22(1)(a) Coroners Act 1996 (WA).

[2025] WACOR 12 (S) BACKGROUND Mr Maher was born on 1 June 1977 in Mullewa and grew up in Northampton.

While being sentenced to a period of imprisonment in 2018, the presiding District Court judge referred to the fact that Mr Maher had endured a very difficult childhood with exposure to alcohol abuse and violence.4 Mr Maher had 10 children and two grandchildren. His employment history included time working as a station hand and a diesel mechanic.

He had also trained at TAFE in Industrial Skills and Landscaping.5 Mr Maher had a substantial criminal history, with a total of 121 criminal court outcomes, and spent much of his life incarcerated.6 He was frank in admitting that his problems, including with the criminal justice system, arose from his methylamphetamine use.7 At the time of his death, Mr Maher was imprisoned on remand at GRP awaiting an upcoming court date on charges of Home Burglary and Commit, Stealing, Possession of Stolen or Unlawfully Obtained Property and Gains Benefit by Fraud.

SECOND LAST PERIOD OF IMPRISONMENT Mr Maher was incarcerated at GRP for four years and nine months from 23 November 2017 to 21 August 2022.

By the time Mr Maher was admitted for this period of imprisonment he had already been diagnosed with hyperlipidaemia which is commonly referred to as high cholesterol. He was prescribed Atorvastatin, a cholesterol lowering medication, to treat his hyperlipidaemia. Prison medical records reflect varying levels of compliance by Mr Maher in terms of taking his prescribed medications.

3 Section 25(3) Coroners Act 1996 (WA).

4 Exhibit 1, Tab 9.1 District Court Sentencing Remarks.

5 Exhibit 1, Tab 10 Department of Justice Health Services Summary Report.

6 Exhibit 1, Tab 2.2 Report of SC CLIFFE.

7 Exhibit 1, Tab 9.1 District Court Sentencing Remarks.

[2025] WACOR 12 (S) Over the course of 2019 health services at GRP conducted ongoing reviews of Mr Maher’s hyperlipidaemia which revealed that his cholesterol and triglyceride levels remained elevated. Triglycerides are a common type of fat that circulate in the body. High blood triglycerides can increase your risk of heart disease, particularly when combined with high cholesterol.

During this time, Mr Maher was supported by prison health services staff in his attempt to lose weight to assist in the management of his hyperlipidaemia.

A routine ECG conducted in 2019 raised no concerns in relation to Mr Maher’s heart.

In January 2021 another routine ECG showed no acute changes when compared with the ECG result from 2019.

It is recorded in notes of a medical review in May 2021 that Mr Maher had succeeded in losing some weight.

In August 2021 Mr Maher was told during a medical review that recent blood tests had shown that his triglyceride levels were continuing to go up. In a bid to combat his rising triglyceride levels, the prison medical officer started Mr Maher on a medication called Fenofibrate.

At a medical review in January 2022, it was noted that Mr Maher’s cholesterol remained elevated despite him being on a maximal dose of Atorvastatin. The prison medical officer requested an updated ECG be conducted for Mr Maher and this occurred in March 2022.

In May 2022 Mr Maher was seen for a medical review to discuss results from recent blood tests and his most recent ECG. He was found to have persistent high cholesterol despite being prescribed medications aimed at reducing his levels. It was noted that Mr Maher was not always compliant with his medications, sometimes declining to take them.

Mr Maher’s most recent ECG result was described as abnormal due to changes seen primarily in the anterior leads. The prison medical officer requested a repeat ECG and referred Mr Maher to a cardiology clinic on a semi-urgent basis. When a referral is made on a semi-urgent basis

[2025] WACOR 12 (S) the intention is that the person be seen by a specialist within 30 to 90 days.

WA Cardiology is a privately run cardiology service with a clinic in Geraldton that accepts referrals for prisoners at GRP. Information provided to the Court by WA Cardiology shows that on 9 May 2022 an appointment was made for Mr Maher to be seen by cardiologist Dr Joseph Hanna on 29 July 2022. This appointment was then moved forward a week to 22 July 2022.

A repeat ECG was done on 31 May 2022 and it again showed the anterior lead changes seen in Mr Maher’s previous ECG.8 On 19 July 2022 the cardiology appointment that was due to go ahead on 22 July was moved to 30 September 2022. While WA Cardiology’s records do not show who instigated the rescheduling of this appointment, they advised that they could see no reason why it would be initiated by them given Dr Hanna, the cardiologist Mr Maher was meant to see, attended Geraldton for a three-day clinic from 22 to 24 July 2022 and had appointments available.

The Department has provided the Court with a spreadsheet detailing the external appointments booked for Mr Maher while in custody. It records the cardiology appointment of 22 July 2022 being cancelled but no reason is specified. Some of the other cancelled appointments on the spreadsheet include reasons such as “offender refused to attend”.

While the Department has been unable to establish the reason for the rescheduling of Mr Maher’s cardiology appointment, it was able to ascertain that GRP’s Senior Medical Receptionist (SMR) was not on duty at the time the appointment was cancelled. Given that the prison’s appointment diary is maintained by the SMR the Department has suggested that, had she been working at the time, she would have been more likely to have recorded the reasons for cancellation.

8 Exhibit 1, Tab 12 Emails from WA Cardiology.

[2025] WACOR 12 (S) On the basis of the information before the Court it seems most likely that GRP initiated the rescheduling of Mr Maher’s cardiology appointment from 22 July to 30 September 2022.

Mr Maher attended a prison medical review on 25 July 2022. It was intended to be a post cardiology appointment review, but the prison medical officer noted in Mr Maher’s record that he had not been seen by a cardiologist yet. The prison medical officer discussed Mr Maher’s abnormal ECG results with him. When Mr Maher advised that he was being released from prison in two weeks’ time, the prison medical officer emphasised the importance of Mr Maher following up his appointment with the cardiologist. It is recorded that Mr Maher was aware he had a heart problem that had not been sorted and he stated he would attend his appointment in the community. The notes of the medical review of 25 July 2022 conclude with a plan for the prison nurse to inform Mr Maher about his specialist appointment and include a note about it on his discharge letter.

Mr Maher was released from GRP on 21 August 2022. The Court has been informed by counsel for the Department that it does not appear that a discharge letter was generated or supplied to Mr Maher upon his release.

WA Cardiology informed the Court that their records show that Mr Maher’s appointment for 30 September 2022 was cancelled when GRP contacted the cardiologist’s rooms on 21 September 2022 to advise that Mr Maher had been released from prison and would arrange his own appointment.9 The GRP medical appointment book for 30 September 2022 has a handwritten entry at 9.30am “Lex Maher WA Cardiology” with a line drawn through it and the notation “cancelled pt released”.10 9 Exhibit 1, Tab 12 Emails from WA Cardiology.

10 Exhibit 1, Tab 9.7 GRP Medical Appointment Diary, dated 30 September 2022.

[2025] WACOR 12 (S) FINAL PERIOD OF IMPRISONMENT Mr Maher was remanded in custody at GRP on 19 October 2022 on charges arising out of an alleged home burglary.

As part of his reception process, Mr Maher was reviewed by a prison nurse on 19 and 20 October 2022. It is recorded that Mr Maher did not voice any concerns from a medical point of view, aside from needing to get back on his medications.

During the nurse review on 20 October 2022 Mr Maher was recorded as being ‘Fit for Sport’.11 WA Cardiology advise that they have a record of receiving a telephone call from GRP on 20 October 2022 asking for a cardiology appointment for Mr Maher but the caller was advised that Dr Hanna was not seeing GRP patients at that time.12 On 26 October 2022 it was arranged for a prison medical officer to rescript Mr Maher’s regular medications which included Atorvastatin and Fenofibrate.

A prison medical officer reviewed Mr Maher’s prison medical records on 14 December 2022 and noted that it was not clear if Mr Maher had been taking his medication regularly while in the community. The prison medical officer was also aware of the fact that Mr Maher had been referred to a cardiologist but was not sure if he had attended the appointment as planned. A prison nurse was tasked with checking if Mr Maher had continued taking his medication in the community and whether or not he had attended his cardiology appointment.

Mr Maher had his Admission Assessment with a prison medical officer on 23 December 2022. During the assessment Mr Maher disclosed he had not been taking his cholesterol medication in the community and had been refusing it in the past week. Mr Maher agreed to a blood test to check his cholesterol levels and was willing discuss the need for medication once those results were back.

11 Exhibit 1, Tab 9.12 Medical Alerts.

12 Exhibit 1, Tab 12 Emails from WA Cardiology.

[2025] WACOR 12 (S) During the Admission Assessment the prison medical officer established that Mr Maher had not attended a cardiologist appointment during his time in the community and rereferral was ordered. It was noted that Mr Maher was keen for the specialist appointment to be rebooked.

Critical Incident In the afternoon on 27 December 2022 Mr Maher was enjoying a game of basketball with fellow prisoners when he stumbled and then collapsed.

Prison officers rushed to Mr Maher’s aid and found him struggling to breath. They supported his head and encouraged him to relax and breath. The officers also placed a towel under Mr Maher’s head and wiped his forehead and face with the end of an icepack in a bid to cool him down. A Code Red medical emergency was called at 4.19 pm.

Medical staff arrived at the basketball court at 4.22 pm and, after examination, commenced cardiopulmonary resuscitation (CPR).

An ambulance was requested at 4.25 pm.

Prison staff administered CPR to Mr Maher on a continuous basis, rotating to ensure maximum efficacy, until the ambulance officers arrived at 4.47 pm.

Mr Maher was transferred into the ambulance on a stretcher with CPR continuing.

As the ambulance was preparing to leave the prison, ambulance officers made the decision to cease CPR in accordance with established Termination of Resuscitation Guidelines.13 Mr Maher was pronounced deceased by one of the attending ambulance officers at 5.15 pm.14 13 Exhibit 1, Tab 14 St John Ambulance Patient Care Records.

14 Exhibit 1, Tab 4 Life Extinct Certification.

[2025] WACOR 12 (S) CAUSE AND MANNER OF DEATH Following a full post mortem examination, including toxicological analysis, forensic pathologist Dr White determined that the cause of death was atherosclerotic heart disease.

Mr Maher’s heart was found to be enlarged and heavily scarred with severe coronary artery disease and thrombosis of the right coronary artery. In simple terms, Mr Maher died from a heart attack.

The only substance identified in toxicological screening was paracetamol15, which did not contribute to Mr Maher’s death.

At the conclusion of the post mortem investigations, Dr White found that the death was due to natural causes.

I accept and adopt the opinion of Dr White, as contained in the post mortem report16, that Mr Maher’s cause of death was atherosclerotic heart disease and the manner of death was due to natural causes.

SUPERVISION, TREATMENT AND CARE As is the case with all deaths in custody, the Department’s Performance Assurance and Risk (PAR) Directorate conducted a review into the death of Mr Maher.17 The review concluded that Mr Maher’s custodial management, supervision and care were in accordance with the Department’s applicable policies and procedures.

It also found that the response to Mr Maher’s collapse was prompt and lifesaving measures were conducted as soon as possible.

Having reviewed the CCTV footage of the incident I concur with the assessment of the staff response to Mr Maher’s collapse. Prison officers and medical staff alike did everything in their power to both comfort and attempt to save Mr Maher. They are to be commended for their 15 Exhibit 1, Tab 7 Toxicology Report.

16 Exhibit 1, Tab 6 Post Mortem Reports.

17 Exhibit 1, Tab 9 Review of Death in Custody Mr Lex MAHER.

[2025] WACOR 12 (S) professionalism and compassion in dealing with this medical emergency.

During the course of her evidence at the inquest, PAR Review Officer Ms Ziino, referred to a thank you card given to the staff at GRP by prisoners following Mr Maher’s death. I have had the privilege of viewing a copy of the card and the expressions of gratitude for the efforts staff made on the day to try and save Mr Maher are heartwarming.

From an overarching perspective, it is clear that Mr Maher received a high standard of health care in diagnosing, managing and monitoring a number of medical conditions during his time in the custody of the Department.

I was assisted by the comprehensive Health Services Summary report compiled by Dr Gunson, Deputy Director, Medical Service which detailed the significant role health services played in Mr Maher’s care while in prison.18 Management of Mr Maher’s cardiovascular risk factors An examination of Mr Maher’s prison medical records reveals that health services staff went to significant lengths to assist him to reduce his modifiable risk factors for cardiovascular disease.

Staff regularly counselled Mr Maher on smoking cessation as well as supporting him to make lifestyle changes including weight loss.

Mr Maher had varying success in this regard and not long before his death he had achieved weight loss of about 6kg.

Mr Maher’s cholesterol and triglyceride levels were closely monitored, particularly following the diagnosis of hyperlipidaemia. He was commenced on Atorvastatin to address his elevated cholesterol levels.

Later, Fenofibrate was added to Mr Maher’s medication regime to combat his persistently high triglyceride levels.

18 Exhibit 1, Tab 10 Health Services Summary into the Death in Custody MAHER, Lex.

[2025] WACOR 12 (S) The Health Service Summary report sets out a long list of screening and preventative health activity provided to Mr Maher by the Department.19 Of significance, given Mr Maher’s cause of death, is the fact that he underwent multiple routine ECGs which meant that new changes were readily identifiable when seen in March 2022 and the appropriate cardiology referral was made.

Taking into account the fact that Mr Maher was not reporting any symptoms associated with a cardiac condition (namely chest pain, shortness of breath or loss in exercise tolerance) there is a high likelihood he would not have been subject to ECG testing at all, let alone regular routine ECGs, if he had been in the community during the period in question.

Given that Mr Maher was asymptomatic at the time a prison medical officer reviewed his abnormal ECG result in May 2022, a semi urgent referral was appropriate.20 Had Mr Maher attended the appointment with WA Cardiology scheduled for 22 July 2022 he would have been seen by a cardiologist within the 90 day timeframe designated for semi urgent referrals. This was clearly a missed opportunity to commence the process of more specialised investigations into the reason for his abnormal ECG results.

While the reason for Mr Maher not attending the 22 July 2022 appointment must remain unresolved, Dr Gunson has been able to assure the Court that the current, updated process in place at GRP for managing prisoners’ external appointments is far more reliable and transparent. It involves a weekly triaging to identify any upcoming appointments that cannot be facilitated by the external transport provider Ventia to allow the Department sufficient time to make alternative transport arrangements. Records of any appointments cancelled by Ventia are kept digitally in a spreadsheet, including the reason for cancellation. When an appointment is cancelled for any other reason, it is recorded in GRP’s appointments diary.

19 Exhibit 1, Tab 10 Health Services Summary into the Death in Custody MAHER, Lex p 9.

20 T 6.

[2025] WACOR 12 (S) The prison medical officer who assessed Mr Maher on 25 July 2022, at what was meant to be a post cardiology appointment review, went to significant lengths to ensure he was aware of the importance of attending the rescheduled appointment which was due to take place after his release from GRP. The prison medical officer’s plan to have the 30 September 2022 appointment with WA Cardiology recorded in Mr Maher’s discharge letter was a sensible one. Unfortunately, a discharge letter was not generated for Mr Maher when he was released from GRP on 21 August 2022.

Having reviewed a template Discharge Letter provided to the Court by counsel for the Department, I can see that they are clearly intended to be a form of medical handover from the Department to a released prisoner’s treating health professional. The title of the MR023 form is ‘Discharge Letter to GP’. 21 It is recorded in Mr Maher’s prison medical records that his usual GP clinic was GRAMS which stands for Geraldton Regional Aboriginal Medical Service.22 During her evidence, Dr Gunson confirmed her understanding that Mr Maher had attended GRAMS in the past and had consented for medical information to be exchanged with them.23 WA Cardiology informed the Court that Mr Maher’s appointment of 30 September 2022 with Dr Hanna was cancelled by GRP on 21 September 2022. The reason provided by GRP for the cancellation was that Mr Maher had been released and would arrange his own appointment.24 The Operations Manager at GRP was consulted and has advised that the only reason the prison would cancel an existing upcoming specialist appointment such as Mr Maher’s cardiology appointment scheduled for 30 September 2022 would be if the prisoner expressed that they needed 21 Exhibit 2 Department of Justice Corrective Services, Health Services, MR 023 Discharge Letter to GP comprehensive.

22 Exhibit 1, Tab 10 Health Services Summary into the Death in Custody MAHER, Lex, Appendix A.

23 T 21.

24 Exhibit 1, Tab 12 Emails from WA Cardiology.

[2025] WACOR 12 (S) to arrange a more suitable date for themselves once they were in the community.

I expect this is what occurred in this instance but, without a clear record of the reason for the cancellation of the 30 September 2022 appointment by GRP, I am left to rely on an explanation as to standard practice.

If it is the case that Mr Maher asked that his 30 September 2022 appointment with WA Cardiology be cancelled so that he could make his own arrangements once he was settled in the community, I still believe that a discharge letter should have gone to GRAMS (with a copy provided to Mr Maher) recording the importance of him taking his own steps to be seen by a cardiologist.

The template Discharge Letter used by the Department includes a number of sections where Mr Maher’s pressing need to be reviewed by a cardiologist could have been recorded including: Active Problems – detailed; Recent Investigations; and Other care required, risks and outstanding referrals.25 Upon returning to custody at GRP on 19 October 2022 I am satisfied that Mr Maher received timely health care. He was very quickly provided with the prescription medication he had stopped taking during his time in the community. This included Atorvastatin and Fenofibrate which were intended to reduce his cholesterol levels and thereby reduce his risk of cardiovascular disease.

The Departmental expectation is that a prisoner should undergo an Admission Assessment by a prison medical officer within three months of coming into custody.26 In Mr Maher’s case, the Admission Assessment took place just over two months after he returned to GRP. It appears to have been a 25 Exhibit 2 Department of Justice Corrective Services, Health Services, MR 023 Discharge Letter to GP comprehensive.

26 T 7.

[2025] WACOR 12 (S) thorough assessment with the prison medical officer identifying that Mr Maher was yet to see a cardiologist and immediately arranging for a referral.

Mr Maher’s Medical alerts recorded during his Nurse Admission Assessment on 20 October 2022 indicate that he was ‘Fit for Sport’. As explained by Dr Gunson during her evidence, the reason Mr Maher would have been cleared to play sport is because he had not presented describing decreased exercise tolerance and he did not yet have an official diagnosis of atherosclerotic heart disease. Dr Gunson went on to explain that even if Mr Maher had been diagnosed with heart disease by the time he came back into custody on 19 October 2022, the Royal Australian College of General Practitioners recommends that people with such a diagnosis maintain fitness and engage in regular exercise.

So that even if Mr Maher was further along the investigative path under the supervision of a treating cardiologist, it would very likely have been reasonable for him to be cleared to participate in activities such as basketball unless he was complaining of chest pain during limited exertion such as walking across the room.27 On this point, it is noted that during the Admission Assessment with a prison medical officer on 23 December 2022 Mr Maher reported that he was able to walk up two flights of stairs without breathlessness.28 Expert report The Court sought the expert opinion of Professor Hillis, the Head of Department of Cardiology at Royal Perth Hospital and Clinical Professor of Medicine at the University of Western Australia.29 Professor Hillis was asked to provide an opinion on the management of Mr Maher’s cardiovascular concerns, particularly after the abnormal ECGs in March and May 2022. He was also asked to comment on the likely significance of Mr Maher not attending a cardiology appointment prior to his death.

27 T 9 -10.

28 Exhibit 1, Tab 10 Health Services Summary into the Death in Custody MAHER, Lex p 23.

29 Exhibit 1, Tab 11 Report of cardiologist Prof. Graham HILLIS.

[2025] WACOR 12 (S) Professor Hillis approved of the decision by the prison medical officer on 5 May 2022 to refer Mr Maher to a cardiologist for investigation of the changes noted on his ECG of March 2022. The referral also sought specialist advice in terms of management of Mr Maher’s persistently high cholesterol levels despite high dose Atorvastatin and Fenofibrate therapy.

The request for a semi-urgent appointment (within 30 – 90 days) was deemed to be reasonable by Professor Hillis given the absence of any concerning cardiovascular symptoms.

Professor Hillis was able to provide the following expert assistance to the Court in terms of a likely pathway had Mr Maher attended an initial cardiology appointment in on 22 July 2022 as planned: “Unfortunately, it is debatable whether even if Mr Maher had been seen within the 3 months requested this would have changed the tragic outcome. It is likely that the referral would have subsequently triggered further investigation, most likely an echocardiogram and possibly either functional testing (stress testing / stress echo etc) or anatomical imaging (coronary angiograph – either invasive or by CT angiography), though there is no certainty that the latter investigations (functional tests or angiography) would have been organised immediately.

Regardless, there would likely have been some delay in obtaining these and it is by no means clear therefore that his severe coronary artery disease would have been diagnosed by the time he died. Indeed, if functional testing had been selected (which would have been very reasonable) that would likely have resulted in some additional delay in proceeding to an angiogram.

In addition, given the severity of the coronary artery disease the ultimate treatment would likely have been coronary artery bypass grafting, so again this may not have occurred prior to the date of death”.30 It cannot be disputed that the best course of action for Mr Maher would have been for him to be reviewed by a cardiologist on 22 July 2022.

30 Exhibit 1, Tab 11 Report of cardiologist Prof. Graham HILLIS p 6.

[2025] WACOR 12 (S) Failing that, then Mr Maher should have been strongly encouraged to retain the rescheduled appointment date of 30 September 2022 with the cardiologist despite the fact that he was being released from custody on 21 August 2022.

It is important to acknowledge that the Department does not have the authority to force a prisoner who possesses decision making capacity to attend a medical appointment when they are in custody, much less once they are released into the community. If Mr Maher insisted that he wanted to arrange his own appointment with a cardiologist once he was in the community then a discharge letter stressing the importance of him doing so should have been generated and sent to GRAMS with a copy provided to him.

However, what the expert opinion of Professor Hillis tells us is that there is no guarantee that, had Mr Maher attended an initial cardiology appointment on 22 July 2022, his death from a heart attack on 27 December 2022 would have been prevented.

Is it likely that the initial review by a cardiologist would have led to further investigations being ordered. Proceeding on the basis that there would almost certainly have been some delay in arranging the various additional examinations, Professor Hillis was not certain that Mr Maher’s severe coronary artery disease would have been uncovered in time to do something about it.

Had a diagnosis been established prior to 27 December 2022, there is again no guarantee that the necessary coronary artery bypass graft surgery would have occurred in time to prevent Mr Maher’s death.

Professor Hollis concluded his report as follows: “My overall conclusion therefore is that although some aspects of Mr Maher’s management could perhaps have been improved slightly, that is something that can almost always be argued for any patient and there are in my opinion no significant issues of

[2025] WACOR 12 (S) concern. Certainly, I can see no evidence that there were major deficiencies in his treatment”.31

CONCLUSION Mr Maher spent the vast majority of his adult life in custody where, on balance, he received a high standard of supervision, treatment and care.

He played basketball with other prisoners during his time in custody and it is evident this was an activity he derived enjoyment from.

When Mr Maher collapsed on the basketball court at GRP on 27 December 2022 the response from prison officers and prison medical staff was timely, compassionate and professional.

From July 2022 there were a number of missed opportunities to ensure that Mr Maher attended an initial review by a cardiologist to further investigate abnormal ECG results. However, had he been seen by a cardiologist prior to his death, it cannot be said that it would have changed the fatal trajectory of his atherosclerotic heart disease.

RM Hartley Coroner 19 March 2025 31 Exhibit 1, Tab 11 Report of cardiologist Prof. Graham HILLIS p 7.