Inquest into the Death of Lex Gregory MAHER
Inquest into the Death of Lex Gregory MAHER
Delivered on : 18 March 2025
Delivered at : Perth
Finding of : Coroner Hartley
Recommendations : N/A
Orders/Rules : N/A
Suppression Order : N/A
Summary : Lex Gregory Maher (Mr Maher) was 45 years old when he died on 27 December 2022 at Greenough Regional Prison. Given Mr Maher was a prisoner at the time of his death, an inquest into his death was mandatory.
Mr Maher was on remand in custody from 19 October 2022 on charges arising out of an alleged home burglary and commit, stealing, possession of stolen or unlawfully obtained property and gains benefit by fraud.
Mr Maher had a diagnosis of high cholesterol and was prescribed medication for this condition. While in custody at Greenough Regional Prison in early 2022, Mr Maher underwent a routine ECG which returned an abnormal result. A repeat ECG produced the same abnormal outcome. As a result, Mr Maher was referred for a specialist cardiology review on a semi-urgent basis. Initially, a cardiology appointment was made for Mr Maher in late July 2022. For a reason that has been unable to be established, the July appointment was rescheduled to 30 September 2022. When Mr Maher was released from prison on 21 August 2022 staff were under the impression, he would arrange his own cardiology appointment once he was in the community, so his 30 September 2022 appointment was cancelled.
Mr Maher returned to Greenough Regional Prison on 19 October 2022. Health services staff noted that he had been due to see a cardiologist and undertook to establish whether that had occurred. Mr Maher had his Admission Assessment with a prison medical officer on 23 December 2022 during which he disclosed he had not been taking his cholesterol medication in the community. He also advised that he had not attended a cardiologist appointment. Mr Maher indicated that he was keen for the specialist appointment to be rebooked.
On 27 December 2022 Mr Maher was playing basketball with fellow prisoners when he stumbled and collapsed. Mr Maher was struggling to breath and staff commenced CPR. Ambulance officers attended and continued CPR. An assessment was made by ambulance officers who determined that resuscitation efforts were futile, and Mr Maher was pronounced deceased.
A post mortem examination established that Mr Maher died as a result of atherosclerotic heart disease.
An expert report concluded that it was uncertain whether a cardiology review in July 2022 would have prevented Mr Maher’s death on 27 December 2022.
The Coroner was satisfied that, on balance, Mr Maher received a high standard of treatment, supervision and care while in the care of the Department of Justice but noted the missed opportunities to ensure he attended a cardiology appointment prior to his death. Mr Maher died as a result of heart disease and, therefore, his death was due to natural causes.
Catch Words : Mandatory Inquest : Death in Care : Natural Causes
Last updated: 1 April 2025