Serial child killer Robert Black smoked heavily for half a century before his death from a heart attack, a doctor told his inquest.
The former delivery driver from Scotland, who preyed on victims as young as five, was at serious risk of cardiac arrest or stroke after a lifetime of little exercise.
High blood cholesterol caused narrowed arteries and underlying medical conditions, a GP and a pathologist said.
Black was found dead in his cell in Maghaberry high-security prison in Co Antrim in January 2016 aged 68.
He murdered four schoolgirls between 1981 and 1986.
Black used tobacco until the end despite complaining of angina chest pains, doctors told his inquest.
He also asked doctors to treat a series of health complaints including a rash on his shin and swelling on his foot, witnesses told coroner Paddy McGurgan, sitting in Armagh courthouse.
GP Dr Joseph Palmer said: “His overall condition would be someone at risk of having a cardiovascular event – that is, a stroke, heart attack or deep vein thrombosis – given that he has already had a stroke and was on a number of medications to hopefully prevent it.
“He also said that he was a smoker not interested in stopping smoking – that risk would have increased.”
For 51 years, Black regularly smoked 25g of hand-rolled tobacco, Dr Palmer told his inquest. The doctor who treated Black said smoking was likely to damage his former patient’s coronary artery.
Black suffered a stroke 20 years earlier and was diagnosed with diabetes in 2015.
Black was found guilty in the same Armagh courtroom in 2011 of sexually assaulting and murdering nine-year-old Co Antrim schoolgirl Jennifer Cardy in 1981 and dumping her body in a dam. She was his first victim, though his trial for her murder was the last to be held.
None of his family members could be traced by the Coroner’s Service, Coroner McGurgan said. His victims’ relatives also stayed away from the inquest, with the professional participants focusing on legal and medical details.
Black, from Falkirk, was serving a number of life sentences when he died. In May 1994, he was convicted of kidnapping, raping and murdering three of his victims.
Susan Maxwell, 11, from Cornhill-on-Tweed in the Borders, was abducted on 30 July, 1982. Her body was finally found on 12 August beside the A518 road near Uttoxeter – more than 250 miles away.
His next victim was Caroline Hogg, five, who was abducted from Portobello, Edinburgh on 8 July, 1983. Her body was found on 18 July more than 300 miles away, close to the M1 motorway in Twycross.
In his job as a delivery driver Black travelled extensively, counsel for the coroner Stephen Ritchie observed.
Sarah Harper, aged 10, was abducted on 26 March, 1986. Her body was found on 19 April in the River Trent near Nottingham, 70 miles from her home in Morley, Leeds.
Jurors were told details of his crimes at the start of the coroner’s hearing, which is expected to last for a week.