Inquest into the Death of Russell Graham PENNY
Delivered on: 9 March 2026
Delivered at: Perth
Finding of: Coroner Tyler
Recommendations: No
Orders/Rules: No
Suppression Order: N/A
Summary: Russell Graham Penny (Russell) was a 56 year old Noongar man who died at Fiona Stanley Hospital on 10 May 2025 from complications of viral hepatitis related advanced-chronic liver disease.
As Russell was a sentenced prisoner at the time of his death, a coronial inquest into his death was mandatory. Russell entered custody on 7 September 2023 after he was convicted of persistently engaging in family violence, and he died before his earliest release date. During his final admission to prison in 2023, Russell was primarily imprisoned at Albany Regional Prison.
Russell had several significant pre-existing medical conditions including diagnoses of asthma, type 2 diabetes, hypertension, hypercholesterolaemia, chronic hepatitis C, and cirrhosis of the liver, secondary to chronic hepatitis C and alcohol misuse.
While in custody, Russell had routine tests to monitor his chronic liver disease. A routine ultrasound undertaken on 15 November 2024 identified new lesions on Russell’s liver, confirmed by a CT scan and blood test which raised the concern that he had developed cancer. Further imaging scans were arranged, and a liver MRI on 24 December 2024 confirmed Russell’s diagnosis of liver cancer. His condition deteriorated significantly through December, and he was classified as a Stage 3 Terminally Ill Prisoner.
Russell was keen for treatment options for his liver cancer to be explored, but after assessment, he was found not suitable for intensive radiation therapy, given the risk this treatment would further damage his liver.
Russell missed an appointment with the Fiona Stanley Hospital Liver Clinic on 5 March 2025. The appointment was scheduled to discuss treatment options after he was found to be unsuitable for radiation therapy. The treatment options that would have been discussed if that appointment went ahead were not about a cure to Russell’s illness, which was terminal. Instead, the discussion would have been about whether any treatment, such as immunotherapy, may have extended Russell’s lifespan, or increased his comfort in the final months of his life. Russell missed this appointment because he had been transferred from Casuarina Prison to Albany Regional Prison. Russell had requested the transfer so he could be closer to family, but the evidence could not establish whether the Department of Justice, or Russell, knew that would mean he would miss a scheduled medical appointment. The appointment was re-scheduled to 21 May 2025 but Russell passed away before that date.
By the time Russell again spoke with the Fiona Stanely Hospital Liver Clinic after he was admitted to the Fiona Stanley Hospital Emergency Department in April 2025, his disease had progressed, and any other treatment options, such as immunotherapy, were no longer possible, if in fact they had ever been.
On 7 May 2025, Russell’s very poor prognosis was explained to him and Russell agreed to end of life care. Russell was provided with regular pain relief, and efforts were made to keep him comfortable until his passing on 10 May 2025.
At the conclusion of an external post mortem examination, a forensic pathologist expressed the opinion that the cause of Russell’s death was complications of viral hepatitis related advanced-chronic liver disease (medically palliated). In the pathologist’s opinion, Russell’s death was consistent with natural causes.
The Coroner was satisfied that the standard of the medical supervision, treatment and care Russell received whilst he was in custody was generally appropriate. The Coroner found that it was unfortunate that Russell had missed his scheduled medical appointment on 5 March 2025 due to his transfer, and encouraged the Department of Justice to consider whether the current processes on the Total Offender Management System (TOMS) database appropriately highlights urgent upcoming medical appointments when custodial movement officers are considering prisoner placements. The Coroner also found that there was a delay in the Department of Justice notifying Russell’s family of his final transfer to hospital, which fortunately did not prevent Russell’s family from visiting him in hospital before his passing.
The Coroner found that Russell died as a result of the progression of his pre-existing illness, and his death occurred by way of natural causes.
Catch Words: Death in Custody, Natural Causes
Last updated: 1 April 2026