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Failure to arrange medical review of prison inmate (13HDC01048)
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(13HDC01048, 1 March
Registered nurse ~ Department of Corrections ~ Delayed
treatment ~ Seizure ~Right 4(1)
A man in his mid-30s was an inmate at a correctional facility.
The man, who was generally healthy, experienced an unwitnessed
blackout. Three days later a nurse was asked to review the man
because he was feeling unwell. Following her assessment the nurse
did not consider the man to be acutely unwell, so she booked him in
to see the general practitioner (GP) at the routine weekly clinic,
six days later.
The man was seen by the GP at the clinic as planned. The GP
considered that the man had possibly been suffering a viral
infection or a "thyroid issue", either of which had resolved. The
GP ordered a thyroid screen and a full blood count.
Three days after the GP assessment the nurse arranged to see the
man to collect blood for the tests ordered by the GP. At that time
the man reported that he had a headache and had vomited that
morning. The nurse took the blood sample but did not examine him.
She noted that she would review him on the afternoon round.
However, this never occurred.
Later that night, at around 10pm, two different nurses, were
asked to see the man due to him having recently had an unwitnessed
seizure and needing to be reviewed. One of the nurses assessed the
man in his cell. The second nurse noted that the man had recently
had a seizure, had banged his head on the wall, and had a lump on
his forehead. She noted that he was feeling a lot better and his
conversation was coherent. The second nurse advised the man to
contact the prison officers overnight if he needed further
assistance, and to see a nurse in the morning. The second nurse
then returned to the health services clinic to record her
At 11.15pm, the man suffered a further seizure, and approval was
sought for prison officers to enter his cell. After a few minutes
the man appeared to have recovered and was able to speak with
prison staff. At approximately 11.30pm, the man suffered a further
seizure, became unconscious, and stopped breathing. Emergency
services were contacted, and two ambulance units arrived at the
prison at 12.05am. After 45 minutes, ambulance officers were able
to detect a pulse, and the man was then transported to hospital.
However, over the next few days he continued to experience seizures
and later died.
It was held that for failing to undertake an adequate assessment
and arranging medical review when she first assessed the man, and
then failing to either review or make arrangements for someone else
to review the man when he later reported a headache and vomiting
the first nurse failed to provide services with reasonable care and
skill and breached Right 4(1). For failing to refer the man for a
medical review following her assessment, the second nurse also
failed to provide services with reasonable care and skill breaching
The Department of Corrections was not found directly liable or
vicariously liable for either of the nurse's breaches of the Code.
However, comment was made about the timeliness of custodial staff
responses to medical emergencies.