Deceased
Tony Ruich
Demographics
55y, male
Coroner
Coroner Urquhart
Date of death
2024-01-10
Finding date
2025-05-08
Cause of death
decompensated liver failure in a man with metastatic hepatocellular carcinoma, with terminal palliative care
AI-generated summary
Tony Ruich, a 55-year-old sentenced prisoner, died from decompensated liver failure due to metastatic hepatocellular carcinoma with terminal palliative care. He had pre-existing cirrhosis diagnosed in 2012, likely from hepatitis C and chronic alcohol dependence. In October 2023, abdominal pain investigations revealed advanced hepatocellular carcinoma with portal vein thrombosis, deemed unsuitable for active treatment. Transferred to Casuarina Prison infirmary for palliative care, he experienced COVID-19 infection and progressive deterioration. On 9 January 2024, he was transferred to Fiona Stanley Hospital where palliative care confirmed imminent death. The coroner found supervision, treatment and care at both facilities was appropriate, though noted the patient frequently declined medical interventions. No preventable failures were identified in his medical management.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Drugs involved
FILE NO/S : CORC 81 of 2024
Catchwords:
Nil
Legislation:
Nil
Counsel Appearing:
Sergeant C Martin assisted the Coroner Mr E Heywood (State Solicitor’s Office) appeared on behalf of the Department
of Justice
Case(s) referred to in decision(s):
Nil
Page }
Coroners Act 1996 (Section 26(1)}
I, Philip John Urquhart, Coroner, having investigated the death of Tony RUICH with an inquest held at Perth Coroner’s Court, Central Law Courts, Court 85, 501 Hay Street, PERTH, on 14 April 2025, find that the identity of the deceased person was Tony RUICH and that death occurred on 10 January 2024 at Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, from decompensated liver failure in a man with metastatic hepatocellular carcinoma, with terminal palliative care in the following circumstances:
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“T am surprised that many people disregard the fact that the end for almost all drug dealers ends up being the cemetery or the jail cell. We do not know of any casc where a drug dealer has ‘retired’.”
Juan Pablo Escobar, son of Pablo Escobar
Tony Ruich (Mr Ruich) died on 10 January 2024 at Fiona Stanley Hospital (FSH), Murdoch, from decompensated liver failure arising from metastatic hepatocellular carcinoma, and after receiving terminal palliative care. He was 55 years old.
At the time of his death, Mr Ruich was a sentenced prisoner in the custody of the Chief Executive Officer of the Department of Justice (the Department)!
Accordingly, immediately before his death, Mr Ruich was a “person held in care” within the meaning of the Coroners Act 1996 (WA) and his death was a “reportable death”? In such circumstances, a coronial inquest is mandatory?
I held an inquest into Mr Ruich’s death at Perth on 14 April 2025.
Dr Catherine Gunson (Dr Gunson), Deputy Director of Medical Services with the Department, gave oral evidence at the inquest.
The documentary evidence at the inquest comprised of one volume of the brief, which was tendered as exhibit 1 at the inquest’s commencement by counsel assisting, Also tendered at that stage was Dr Gunson’s Health Services Summary into Mr Ruich’s death dated 11 April 2025. That document became exhibit 2.
The inquest focused on the medical treatment and care Mr Ruich received in prison and in hospital in the months before he died.
In making my findings, 1 have applied the standard of proof as set out in Briginshaw v Briginshaw (1938) 60 CLR 336, 361-362 (Dixon J) which requires a consideration of the nature and gravity of the conduct when deciding whether a matter adverse in nature has been proven on the balance of probabilities.
I am also mindful not to insert hindsight bias into my assessment of the actions taken by individuals in their supervision, treatment and care of
' Prisoners Act 1981 (WA)s 16 2 Coroners Act 1996 (WA) s 3 and s 22(1)(a) 3 Coroners Act 1996 (WA) s 253)
Mr Ruich. Hindsight bias is the tendency, afler an event, to assume the event was more predictable or foreseeable than it was at the time.*
9 Mr Ruich was born on 24 December 1968 in Osborne Park, Perth, to Croatian parents. He left school part way through Year 11 as he found it boring and not worthwhile. Although his parents, who were hardworking, tried to persuade him to work on the family farm, Mr Ruich left the family home when he was 20 years old.
10 Unfortunately, Mr Ruich began a life of offending and illicit drug use which included cannabis, LSD, methylamphetamine and eventually heroin, for which he had a long-term dependency. When he was taken into custody for the final time, Mr Ruich said he was intravenously using “a couple of grams a day” of heroin.®
12 In November 2010, he received his third term of imprisonment (3 years) for another heroin dealing related charge.
Circumstances of Mr Ruich’s final imprisonment
: 14 On 1 April 2019, Mr Ruich was remanded in custody after being charged with a number of serious offences that were drug-related. These alleged offences had been committed whilst he was on bail for other charges.
15 Mr Ruich eventually pleaded guilty to nine offences that included possession of heroin with intent to sell or supply, possession of methylamphetamine with intent to sell or supply, two offences of possession of a firearm with circumstances of aggravation, and two offences of possession of stolen or unlawfully obtained money.
4 Dillion H and Hadley M, The Australasian Coroner’s Mamiul (2015) 10
5 Exhibit 1, Tab 2, Report of Coronial Investigator dated 30 April 2024; Exhibit 1, Tab 9, Review of Death in Custody dated August 2024; Exhibit 1, Tab 10.1, District Court sentencing transcript dated 29 October 2020 ® Exhibit 2, Health Services Summary into the Death in Custody, p.5
He was sentenced in the Perth District Court on 29 October 2020 for these offences to a term of imprisonment of 10 years 4 months. This sentence was backdated to commence on 2 February 2019 to reflect Mr Ruich’s time already served in custody. This meant his earliest eligible date for release on parole was 1 June 2027.
On 6 November 2020, Mr Ruich appeared via video-link from prison in the Perth Magistrates Court and pleaded guilty to numerous summary offences from 2017 to 2019 that were predominantly drug or weapon-related. He received a global fine for these matters.
Prison placement for Mr Ruich’s final imprisonment
From 1 April 2019, Mr Ruich was placed in the following prisons:
e Hakea Prison: | —4 April 2019 (3 days) e Casuarina Prison: 4 April 2019 — 20 November 2020 (596 days) e Acacia Prison: 20 November 2020 — 1 December 2022 (741 days)
e Wooroloo Prison Farm: 1 December 2022 — 24 November 2023 (358 days)
e Casuarina Prison: 24 November 2023 — 10 January 2024 (48 days)
During his final term of imprisonment, Mr Ruich was reported to be a quiet prisoner who did not come to the attention of custodial staff He complied with the rules and regulations and was not considered to be a management problem. Mr Ruich maintained his cell and person hygiene to the required standards.
Prior to his final term of imprisonment, Mr Ruich had already been diagnosed with some serious health conditions, including chronic hepatitis C, cervical spinal spondylosis and cirrhosis of the liver which had been diagnosed in 2012. The liver cirrhosis almost certainly arose from his hepatitis C and long-term alcohol dependency.
As at August 2023, Mr Ruich was in Wooroloo Prison Farm (Wooroloo),
7 Exhibit 1, Tab 9, Review of Death in Custody dated August 2024; Exhibit 2, Health Services Summary into the Death in Custody
Page §
Mr Ruich is taken to St John of God Midland Hospital on three occasions
23 On 22 October 2023, Mr Ruich attended the health centre at Wooroloo and complained of ongoing lower abdomen pain. He was subsequently taken to St John of God Midland Hospital (SJOGMB) for assessment. A CT scan showed a cirrhotic liver with features of portal hypertension including splenomegaly (enlarged spleen) and trace ascites (fluid within the abdominal cavity that can occur with cirrhosis of the liver). It was noted that due to difficulties with cannulation, there were limitations on what could be identified on the scan.
| remained after 48 hours or worsened, he should reattend the ED at
25 By 25 October 2023, Mr Ruich still reported pain in his lower abdomen. He was again taken to SJOGMH for further assessment. On this occasion, it was assessed that Mr Ruich may have possible gastro-oesophageal reflux
J disease (GORD). He was prescribed analgesia and pantoprazole, and
| returned to Wooroloo the same day with a plan to return to SIOGMH if
| symptoms persisted.
26 On 8 November 2023, Mr Ruich reported to a nurse at Wooroloo that he was feeling bloated, which had existed for the previous two weeks. Despite | drinking a lot of water, he was unable to urinate. On that day, Mr Ruich was taken to the ED at SJOGMH for a further assessment.
27 On this oecasion, Mr Ruich remained an inpatient for 16 days. He underwent further CT scanning which found potential hepatocellular carcinoma (the most common form of liver cancer) and portal vein thrombosis. He was also diagnosed with ascites.
28 On 17 November 20223, upon confirmation that Mr Ruich did have hepatocellular carcinoma, his case was discussed at the Hepatology Multidisciplinary Team at Royal Perth Hospital (RPH). It was noted that due to decompensated liver failure, Mr Ruich was not suitable for active
treatment, A decision was made that Mr Ruich would be treated palliatively when required.
Following this diagnosis, the Department determined that Mr Ruich would be discharged to Casuarina Prison (Casuarina) where he could be treated in the infirmary. On 24 November 2023, Mr Ruich was discharged from SJOGMH. with multifocal hepatocellular carcinoma as the principle diagnosis.
Mr Ruich’s medical treatment at Casuarina
Following his placement in the Casuarina infirmary, Mr Ruich tested positive to the COVID-19 infection (COVID-19) on 26 November 2023.
He was prescribed anti-viral medication and remained in medical isolation with daily reviews by a nurse.
At this time, a review consultation was conducted with the Hepatology Multi-Disciplinary Team at RPH which confirmed there was no active treatment options available for Mr Ruich and that palliative care would be maintained.
Mr Ruich continued to test positive to COVID-19 until 5 December 2023.
On 11 December 2023, the prison doctor discussed Mr Ruich’s prognosis with him and Mr Ruich agreed to have a “not for resuscitation” status.
Although the prognosis was uncertain, it was felt that Mr Ruich likely life expectancy could be measured in months. He also advised that he wanted to speak to his lawyer concerning his will and family matters. Mr Ruich later met with his lawyer on 20 December 2023.7
During December 2023 Mr Ruich continued to have his daily nurse reviews. On 12 December 2023, a review by the prison doctor recommended that Mr Ruich be transferred out of the infirmary. On 22 December 2023, a palliative care review was conducted. The palliative care team recommended that Mr Ruich’s weight be checked on a weekly basis, nursing staff monitor his bowel movements and his blood sugar levels be regularly checked.! It was noted there should be a follow-up palliative care review in three to four weeks, or earlier if needed.
On 4 January 2024, Mr Ruich experienced a significant exacerbation of abdominal swelling. Casuarina medical staff noted a recurrent ascites due
® Casuarina is the only male adult prison in the state that bas an infirmary.
° Email from Mr Heywood to counsel assisting dated 13 April 2025 ‘© Mr Ruich had been diagnosed with type-2 diabetes in October 2022,
to the decompensated liver cirrhosis and hepatocellular carcinoma.
Mr Ruich was then scheduled for a hospital day procedure on 10 January 2024 to drain the ascites. This was later rescheduled for 15 January 2024 due to an oversight by the prison doctor to stop one of Mr Ruich’s medications in the period before the procedure.
36 On 8 January 2024, Mr Ruich had a further increased level of ascites with diffused abdominal discomfort. He also had disturbed sleep associated with intermittent visual hallucinations and peripheral oedema.
EVENTS LEADING TO MR RUICH’S DEATH "' Mr Ruich is taken to Fiona Stanley Hospital
37 On the morning of 9 January 2024, Mr Ruich had an appointment with the prison doctor and it was noted there was an obvious decline in his health.
At the medication parade in Mr Ruich’s unit that afternoon, nursing staff saw that he was very unwell. However, Mr Ruich refused to be admitted into the infirmary.
38 Mr Ruich was eventually taken to the infirmary at 5.30 pm for further assessment and the decision was made to immediately transfer him via ambulance to FSH. It was determined that due to his ill health and previous good behaviour, Mr Ruich was not to be restrained in any manner during his transfer to FSH or any subsequent hospital admission. | am satisfied this was a correct application of the Department’s policies and procedures regarding the non-restraining of terminally ill prisoners who require a hospital admission.
39 Mr Ruich was admitted to FSH due to worsening ascites. He was noted to be experiencing shortness of breath, and was tachycardic and hypotensive.
A CT scan of Mr Ruich’s abdomen showed numerous focal low density lesions in both lobes of the liver and there were features of possible portal vein thrombosis, Numerous bilateral round lung lesions were present, raising concerns of metastasis.
| 40 Due to the advanced stage of his decompensated liver failure, it was diagnosed that Mr Ruich’s death was imminent. The decision was made that he would only receive palliative treatment.
4, The Department has had a long-term arrangement of outsourcing the guarding of a prisoner who has been admitted to hospital to Ventia, a
4 Exhibit 1, Tab 6.2, Supplementary Post Mortem Report dated 18 April 2024; Exhibit |, Tab 9, Review of Death in Custody dated August 2024; Exhibit 2, Health Services Summary into the Death in Custody
private company. This is known as a “hospital sit”. Officers from Ventia took over the hospital sit for Mr Ruich from prison officers at 5.14 pm on 10 January 2024,
At about 10.05 pm on 10 January 2024, Ventia officers saw that Mr Ruich was not moving. At 10.18 pm, a doctor at FSH certified Mr Ruich as life extinct.'? Mr Ruich’s partner was able to be present by his bedside at the time of his death.
On 19 January 2024, Dr Joe Ong (Dr Ong), a forensic pathologist, conducted a post mortem examination on Mr Ruich’s body and reviewed the relevant hospital records.
The post mortem examination found yellow discolouration of the skin and in the white of the eyes, in keeping with jaundice. The liver had a firm and nodular appearance, consistent with cirrhosis. Liver nodules were also present, in line with the history of hepatocellular carcinoma.
Multiple lung nodules were also detected within both lungs and there was fluid within the abdominal cavity (ascites). There was hardening, thickening and narrowing of the vessels supplying the heart muscle (coronary artery atherosclerosis).
Microscopic examination of tissues from the major body organs confirmed the presence of metastatic hepatocellular carcinoma with metastatic tumour deposits within the lungs, and a tumour thrombus within the portal vein.
The existence of coronary artery atherosclerosis was also confirmed.
A toxicological analysis of blood and urine samples from Mr Ruich detected medications in keeping with his hospital care.
At the conclusion of the post mortem investigations, Dr Ong expressed the opinion that the cause of death was decompensated liver failure in a man with metastatic hepatocellular carcinoma, with terminal palliative care.
I accept and adopt the opinion expressed by the forensic pathologist as to the cause of Mr Ruich’s death, and I find that death occurred by way of natural causes.
2 Exhibit [, Tab 4, Death in Hospital form dated 10 January 2024 13 Exhibit 1, Tab 6, Interim Post Mortem Report dated 9 January 2024; Tab 6.1, Post Mortem Report dated 9 January 2024; Tab 6.2, Supplementary Post Mortem Report dated 18 April 2024
At Casuarina
50 Having reviewed all the information available, I am satisfied that the supervision, treatment and care Mr Ruich received at Wooroloo from August 2023, and then at Casuarina from 24 November 2023 until his death, was appropriate.
51 Prisoners have less restrictions at the minimum-security Wooroloo compared to the maximum-security Casuarina. In Mr Ruich’s case, his good behaviour had meant he was permitted to reside in a self-care unit at Wooroloo. However, 1 am satisfied it was necessary for Mr Ruich to be transferred to Casuarina on 24 November 2023 due to his deteriorating health and the need for him to have ready access to the only adult prison infirmary in the state.
Nevertheless, I am satisfied he received appropriate care from health service providers at Casuarina for the management of his liver cirrhosis and hepatocellular carcinoma.
53 I accept Dr Gunson’s evidence that Mr Ruich “was only intermittently
adherent to medical management whilst he was in custody, either missing
| or refusing multiple booked appointments with doctor and nurses.” He
| also regularly refused investigations if he needed to leave prison in order to
| be seen by an external health services provider. In addition, Mr Ruich
“often refused to have updated blood tests, due to the immense difficulties
in obtaining samples (this was due to blood vessel damage for his long
injecting history}.”'® | also accept Dr Gunson’s explanation that as
Mr Ruich had capacity, he had the right to accept or decline health care during his various terms of imprisonment."”
Mr Ruich’s placement on the Terminally Ill Register
54 | have also examined the classifications that were made for Mr Ruich under the Department’s Commissioner’s Operating Policy and Procedure 6.2: Prisoners with a Terminal Medical Condition (COPP 6.2). A prisoner is
" Exhibit |, Tab 9, Review of Death in Custady dated August 2024; Exhibit 2, Health Services Summary into the Death in Custody
8 Exhibit 2, Health Services Summary into the Death in Custody, p.23
© Exhibit 2, Health Services Summary into the Death in Custody, p.23
" Rxhibit 2, Health Services Summary into the Death in Custody, pp.24-26
placed on the Terminally Il Register when it is recognised their health conditions may significantly increase their potential to die in custody, having regard to the nature of the health conditions and the length of their sentence. I am satisfied that, in general, Mr Ruich received the appropriate classifications which were made in a timely manner.
One of the outcomes of these classifications is that a prisoner who is classified at Stage 3 (having a terminal medical condition and is likely to die within three months) or Stage 4 (having a terminal illness and death is imminent)'* can be released on compassionate grounds by the Governor before the expiration of their term of imprisonment. This is known as the grant of a pardon in the exercise of the Royal Prerogative of Mercy.
If a prisoner is classified at Stage 3, the Department must, within seven working days of the notification of the classification, prepare a briefing note to the Minister for Corrective Services (briefing note). If the classification is at Stage 4, then the briefing note must be prepared within three working days of the notification of the classification.””
The information in the briefing note includes the prisoner’s medical situation, their life expectancy and the likelihood of the prisoner dying in custody?!
No briefing notes were prepared for Mr Ruich by the Department’s Sentence Management Division which was responsible for the preparation of these briefing notes.
Although Mr Ruich was classified at Stage 3 on 17 November 2023, he was reclassified to Stage 2”? four days later on 21 November 2023 due to his hospital admission at the time and his ongoing medical treatment.”? As a weekend fell on 18 and 19 November 2023, there had only been one full working day before Mr Ruich was reclassified to Stage 2. In those circumstances, | am satisfied there was an adequate explanation as to why no briefing note was prepared whilst he was at Stage 3.
'8 COPP 6.2 (version 2.0}, pp.4-6
‘9 COPP 6.2 (version 2.0), p.5
20 COPP 6.2 (version 2.0), p.6
21 COPP 6.2 (version 2.0), pp.7-8
2 Stage 2 means the prisoner is likely to die within 12 months but is unlikely to die within three months: COPP 6.2 (version 2.0), p.4
23 Exhibit 1, Tab 9, Review of Death in Custody dated August 2024, p.L1
60 T also note it was documented at the time Mr Ruich was reclassified to Stage 2 that should he be reclassified back to Stage 3, a briefing note would be prepared.”
61 From the information available, it would appear Mr Ruich remained on Stage 2 until 9 January 2024. With the benefit of hindsight, the question might be raised as to why Mr Ruich remained on Stage 2 for that length of time, given that the treatment for his hepatocellular carcinoma was only ever going to be palliative.
62 Inher evidence at the inquest, Dr Gunson noted that Mr Ruich could have remained at Stage 3 during this period. However, to now be critical of the Department for not keeping Mr Ruich at Stage 3 or not placing him back to Stage 3 earlier, would be to insert impermissible hindsight bias. I therefore make no such finding.
63 On 9 January 2024, Mr Ruich was classified at Stage 4. However, he was then placed on Stage 3 the next day based on some preliminary information provided by FSH.** Yet on that same day, 10 January 2024, he was placed back on Stage 4 after the Department’s Health Services received a more detailed update from the physician at FSH managing Mr Ruich’s palliative care. As already noted, Mr Ruich died on the evening of 10 January 2024,
64 Understandably, there was very little time for the Department to prepare a briefing note over the 24 hour period from 9 to 10 January 2024. However, given Mr Ruich’s extremely poor prognosis once he had been admitted to FSH and on the background of his poor prognosis since November 2023, it
| may not have been entirely necessary to, albeit very briefly, reclassify him | from Stage 4 down to Stage 3 on 10 January 2024. With the benefit of | hindsight, the better course of action might have been to wait for a more | detailed update.
65 Notwithstanding that observation, I must make it clear that this did not alter the outcome of any potential exercise of the Royal Prerogative of Mercy as | Mr Ruich died only a matter of hours later. In addition, even if he had lived | longer, this change from Stage 4 to Stage 3 and then back to Stage 4 would have had little bearing on the timing of the briefing note as the Department was still required to prepare the briefing note within three working days.”°
% Lyxhibit 1, Tab 9, Review of Death in Custody dated August 2024, p.12 25 xhibit 1, Tab 9, Review of Death in Custody dated August 2024, p.14 26 Although the Department may have been able to prepare the briefing note within three working days from 10 January 2024, rather than 9 January 2024. As three working days ftom Wednesday, 10 January 2024 incorporated a weekend, this meant the briefing note had to be prepared by Monday, 15 January 2024 (compared to Friday, 12 January 2024 if it was calculated from Tuesday, 9 January 2024).
At FSH
Shortly after Mr Ruich had been admitted to FSH on the evening of 9 January 2024, medical treatment had confirmed he was gravely ill with no prospects of recovery. The only option was for medical staff to commence palliative care to make Mr Ruich as comfortable as possible. In those circumstances, | am satisfied that Mr Ruich’s care and treatment at FSH was appropriate.
I also commend FSH and the Department for making the necessary arrangements to have Mr Ruich’s partner by his bedside when he died.
Mr Ruich developed some serious health conditions after he was imprisoned on | April 2019 for the final time. Over the following years, he was diagnosed with type-2 diabetes, pulmonary embolism, ascites associated with his cirrhosis of the liver, and finally hepatocellular carcinoma which, in combination with his cirrhosis, led to decompensated liver failure.
Hepatocellular carcinoma is the most common form of primary liver cancers and can either be a single tumour or multiple tumours. It is an aggressive cancer and often symptoms only appear in the later stages of its progression. This means it is commonly only detected when it is at an advanced stage, and hence it is extremely difficult to cure.
Sadly, upon his diagnosis of hepatocellular carcinoma in November 2023, Mr Ruich’s anticipated life expectancy was always going to be measured in months rather than years. He therefore had very little prospect of being considered cligible for parole in 2027.
I was satisfied that the supervision, treatment and care Mr Ruich received in the final months of his life by custodial staff and health service providers at Wooroloo and Casuarina was appropriate. I accept the following summary by Dr Gunson regarding the health care Mr Ruich received (which also covered his previous terms of imprisonment):?"
In conclusion, the care provided to Mr Ruich was holistic and patient-centred. By his own admission, he sought little to no health care in the community, and frequently declined reviews, tests and interventions whilst in custody. Knowing this, prison health staff ensured
7 Exhibit 2, Health Services Summary into the Death in Custody, p.27
that during his sojourns in custody, where possible, he was regularly offered opportunities to change his mind or to request tests or treatments.
I was also satisfied that the treatment and care Mr Ruich received during his final hospital admission at FSH was appropriate.
Finally, 1 refer to a matter raised by Dr Gunson in her Health Services Summary to the Court?® and then in her evidence at the inquest. This concerned the question of introducing ultrasound and/or fibro scan services at Casuarina to enable improvements to be made in the detection of cirrhosis, hepatitis C and hepatocellular carcinoma amongst prisoners.
At the completion of the inquest, I sought the Department’s response to the Court making recommendations in this area. By email dated 7 May 2025, Mr Heywood, counsel for the Department, attached a one page response from the Department regarding the proposed recommendations that I was considering in light of Dr Gunson’s evidence.
Neither of the proposed recommendations was supported. Amongst its reasons, the Department advised that its health service providers lack the necessary skillsets to provide these services. It also stated that as the Department is “only funded to provide primary health care to prisoners, all secondary and tertiary health care is provided by the Department of Health and therefore any imaging undertaken by the Department would need to be repeated by an external public specialist.”
As I have noted in other inquest findings, the Court must always exercise caution when making recommendations that do not have the support of the relevant government department. Consequently, [ have decided not to make any recommendations that, if implemented, would most likely improve the ability of the Department’s Health Services to early detect cirrhosis and hepatitis C, two serious health conditions that Dr Gunson noted are particularly rife amongst male prisoners.
Mr Ruich had certainly led a life of risk-taking. He had developed a long-standing dependency on alcohol and illicit drugs, with heroin becoming his preferred drug for much of his adult life. The Court is acutely aware of the inevitable impact long-term illicit drug taking and excessive alcohol consumption has on a person’s quality of life and their life expectancy.
28 Exhibit 2, Health Services Summary into the Death in Custody, p.26 22 Email from the SSO to the Court dated 7 May 2025, Attachment p.1
78 Despite three previous terms of imprisonment for drug dealing, Mr Ruich was never effectively rehabilitated from his criminal behaviour or illicit drug dependency before his final, and longest, prison sentence began in
79 Textend my condolences to the family and loved ones of Mr Ruich for their loss.
PJ Urquhart Coroner 8 May 2025
Page [5
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