A government health agency has apologised to the family of an Indigenous man who died in jail, after a coroner found his illness was not properly diagnosed and treated.
Aboriginal and Torres Strait Islander readers are advised that this article contains images and names of people who have died.
William Haines's principal once told family and friends the boy from Moree, NSW, was gifted and could well grow up to be the first Aboriginal astronaut.
But at the age of 37 Mr Haines was found unresponsive on the floor of his cell in Cessnock Correctional Centre.
In findings released today, Deputy State Coroner Carmel Forbes found the Bundjalung and Gomeroi man died of natural causes, but said there were shortcomings in his care.
She noted that in the six years prior to his death Mr Haines was admitted to three different Sydney hospitals and treated for deep vein thrombosis (DVT), a condition that caused the pulmonary embolism he died from.
But when Mr Haines was unwell and transferred from Cessnock prison to the local hospital in March 2021, the transfer documents did not include that history.
The doctors at Cessnock hospital never investigated DVT as a cause of Mr Haines's symptoms.
Instead he was treated for a heart condition called endocarditis.
The inquest heard from medical experts that the diagnosis "pigeonholed" Mr Haines into a particular diagnostic pathway as he was moved from Cessnock Hospital to Maitland Hospital and finally to John Hunter Hospital in Newcastle.
At John Hunter, endocarditis was finally ruled out and after nine days Mr Haines was discharged with "atypical chest pain", which was described to the court as a "throw-away" diagnosis.
The coroner concluded that this diagnosis led to Mr Haines receiving a different level of care from Justice Health than what he would have received had a pulmonary embolism been diagnosed.
Mr Haines died inside his cell five weeks after his return to Cessnock jail.
Magistrate Forbes noted that Mr Haines was handcuffed to his bed throughout his treatment.
She wrote that the evidence was clear that a lack of mobility increased the risk of DVT, but accepted that alternatives to being treated as Mr Haines was presented considerable difficulties in terms of safety and security.
Magistrate Forbes accepted that measures had been taken to prevent a similar deaths, including changes in policy requiring Justice Health to share medical alerts for prisoners with external hospitals.
She also noted that Hunter New England hospitals required DVT risk assessments of patients before any medication could be prescribed.
In a statement, the acting chief executive of Hunter New England Health Tracey McCosker offered her "sincere condolences" to Mr Haines' family.
"And apologise that we did not provide him with the standard of care he deserved," she said.
"We will work through the Coroner's findings and look at ways we can further improve our standards of care."
