Coroner recommends prison communication review after Lathan Brown's death

Australia Broadcast Center

3 days ago

A New South Wales coroner has called for changes to prison communication systems to ensure loved ones are kept informed in life-threatening situations.
The recommendation comes after an inquest into the death of a young Aboriginal man who died in custody without the chance for a final goodbye.
Aboriginal and Torres Strait Islander readers are advised this article contains the name and image of a person who has died.
Kamilaroi and Barkindji man Lathan Brown, 28, died at Orange Hospital on January 6, 2024, after he was found unresponsive in his cell at Wellington Correctional Centre earlier that afternoon.
An inquest in Dubbo heard he had no known medical conditions and was on remand for minor property offences.
A breakdown in communication between Corrective Services and his family meant they were unable to be by his bedside before resuscitation efforts were stopped.
"I did not get to see my son Lathan alive one last time," his father, Michael Brown, said.
"Lathan passed away without his family being with him, and this is still deeply horrifying and upsetting to me.
"There was time wasted where we could have spent with him and we can never get that time back."
Deputy State Coroner Stuart Devine found the "tragic and unexpected death" was the result of a cardiac arrhythmia and could not have been avoided.
However, he identified serious failures in how the family was kept informed.
He recommended Corrective Services NSW review its systems to ensure families were kept informed when a person in custody was critically ill or transferred to hospital.
The coroner also called for improvements to the intercom used for distress calls in cells at Wellington Correctional Centre, and recommended reviewing staff handover procedures.
The inquest heard that about 3:40pm on the day of Mr Brown's death, his cellmate, who was showering at the time, heard him coughing and found him unresponsive on the floor.
Paramedics arrived and took Mr Brown to Wellington Hospital, where his pulse was briefly restored, but he remained unconscious and unable to breathe independently.
Mr Brown's grandmother, who was listed as his emergency contact, was phoned by Corrective Services and told his condition was "dire", but no further updates were provided.
Michael Brown, who was in Orange at the time, was told by a family member that his son was being transferred to Dubbo Hospital.
He drove nearly two hours, only to learn his son was still at Wellington and would be transferred to Orange instead.
Mr Brown then drove to Wellington Hospital, but was denied access to see his son for "security reasons".
He arrived at Orange Hospital 10 minutes after medical staff decided to take his son off life support.
"The heartbreak of lack of communication on that night, not getting updates on his condition and not being told of his whereabouts has resulted in endless pain," Mr Brown said.
Lathan Brown, who grew up in Weilmoringle and Bourke, was described as the "life of the party" and proud of his Indigenous heritage.
His family and friends remembered him as a respectful young man and a "pleasure to be around".
He is one of more than 600 First Nations people who have died in custody since the 1991 Royal Commission into Indigenous Deaths in Custody.
The inquest heard his criminal justice contact involved "relatively minor matters" related to drug use after his mother's death.
Aboriginal Legal Service solicitor Tia Caldwell urged Corrective Services to act swiftly to prevent the same thing happening to other families.
"Aboriginal people are imprisoned at almost 11 times the rate of non-Indigenous people in NSW," Ms Caldwell said.
"It has been an extremely long process for Michael Brown and his family. He's devastated he did not get to say goodbye to his son, causing endless pain.
"Everyone deserves to have their loved ones beside them in their final hours, but this opportunity was taken from Lathan and his family because of communication deficiencies."