A summary inquest into the September 2019 death of a 42-year-old inmate at Ararat's Hopkins Correctional Centre determined that the death was not suspicious.
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Coroner Katherine Lorenz oversaw an investigation into the death of Travis Thomas Young, 42, following reports that he may have been murdered.
Mr Young had accumulated debts with prisoners, and following his death, several inmate anonymously reported they sensed foul play.
"My role, which is to independently investigate the death of Mr Young, and to ascertain three things: his identity, the cause of his death and the circumstances in which his death occurred," Ms Lorenz said.
"There is no issue about identity or about the medical cause of death, so what I'm primarily interested in is aspects of the circumstances in which he died."
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The coroner said a secondary role might be identifying any potential prevention opportunities and making recommendations to the minister's public statutory authorities.
"As part of the coronial investigation, the coroner's coronial investigator prepared a briefing this matter," Ms Lorenz said.
"The brief includes statements from relevant witnesses. It has incorporated both the reports from JARO (Justice Assurance and Review Office) and Justice Health into Mr Young's death."
Justice Health is a business unit of the Department of Justice and Community Safety.
Senior Coroner's Court solicitor Dylan Rae-White presented a summary of the evidence to the court, outlining Mr Young's incarceration and final years before his death.
On December 18, 2009, Mr Young was sentenced to 15 years of imprisonment with a non-parole period of 11 years.
He was initially placed in Port Phillip Prison but was transferred to Hopkins Correctional Centre in December 2013.
Mr Rae-White said the inmate's behaviour in the correctional centre was good enough to move to a cottage in prison living amongst a small cohort of prisoners.
Mr Young had several ongoing health issues, including tinnitus, generalized anxiety disorder and insomnia.
He was on an opioid substitution therapy program and was taking methadone daily.
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In May 2019, Mr Young presented to staff on numerous occasions detailing ongoing distress relating to tinnitus.
Mr Rae-White said Mr Young received the steroid dexamethasone for tinnitus and melatonin to aid sleep.
Despite the treatment, Mr Young's high anxiety and insomnia persisted.
On August 23, 2019, Mr Young told a staff member he was having trouble with his tinnitus and was worried he might hurt himself or someone.
Mr Rae-White told the court that at the time of his death, Mr Young was awaiting allocation for an appointment with an ear, nose and throat specialist at St Vincent's Hospital in Melbourne.
He has previously been referred but had refused the referral to an appointment in August 2018 because he did not want to travel to a hospital as it would have required him to transfer to Port Phillip Prison.
There is no issue about identity or about the medical cause of death, so what I'm primarily interested in is aspects of the circumstances in which he died.
- Coroner Katherine Lorenz
On September 30, 2019, a fellow prisoner said he spoke with Mr Young and said he looked pale.
The court heard that Mr Young was later found unresponsive in the cottage bathroom.
A Code Black - a situation related to an inmate or staff member's safety - was initiated.
Ambulance Victoria attended the scene, but the deceased could not be revived.
On October 3, 2019, a forensic pathologist practising at the Victoria Institute of Forensic Medicine provided a report on Mr Young's death.
The forensic pathologist wrote there was no evidence available to indicate the involvement of any other person, Mr Rae-White said.
Later in October 2019, staff were informed about a potential third party involvement.
The court heard Mr Young had accumulated debts with prisoners of considers.
Mr Rae-White said Ararat Senior Constable Mal Weinberg provided a signed statement related to his investigation of Mr Young's death.
Sen Const Weinberg stated that around October 2019, several Hopkins Correction Centre prisoners believed Mr Young's death was a consequence of foul play.
The court heard Sen Const Weinberg dismissed this belief because there was no evidence of a struggle at the scene of Mr Young's death or defensive wounds.
Justice Health prepared a secondary report about the management of Mr Young's health whilst in custody.
It made recommendations for systemic improvements arising from Mr Young's death; overall, JARO made two recommendations, and Justice Health made five.
Corrections Victoria accepted all recommendations.
Coroner Lorenz did not find any missed opportunities for intervention or prevention in the circumstances surrounding Mr Young's death.
"The coronial investigation has not yielded any evidence that any other person was involved in Mr Young's death, or that he otherwise died in suspicious circumstances," Ms Lorenz said.
"I'm satisfied that Victoria Police investigated the anonymous allegations and find that those allegations are without substance.
"I convey my sincere condolences to Mr. Young's family for their loss."
If this article has raised issues for you, or if you're concerned about someone you know, call Lifeline on 13 11 14.
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