Coronial Inquest into the death of Judy Sonia BOLTON
Delivered on: 20 August 2019
Delivered at: Perth
Finding of: Coroner Jenkin
Suppression Order: N/A
Summary: At the time of her death, the deceased was in the care of the then Department of Corrective Services as a remand prisoner on unit 1 at at Bandyup Womenâ€™s Prison (Prison). The deceased died on 10Â December 2016 at Royal Perth Hospital from acute myocardial infarction due to a coronary thrombosis.
At about 5.30 pm on 10 December 2016, the deceased developed pain whilst eating dinner and tried to walk it off prior to seeking help. She rang her daughter and said she was having chest pains and was going to lie down for a moment. The deceased rang her daughter a short time later to say she had indigestion and was feeling better. At 6.15 pm a fellow prisoner made a cell call alarm and advised that deceased was unwell. The unit 1 control officer called a â€˜Code Greenâ€ on the prison radio to indicate a non-emergency situation that required the attendance of a nurse. A short time later, a nurse accompanied by two custodial officers arrived at unit 1 to attend to the deceased.
The deceased told the nurse she had eaten some chilli tuna and noodles. She was calm and did not appear to be distressed. The deceased walked across the unit 1 courtyard to the control room where she was placed into a wheelchair and taken to the Prison medical centre for further assessment. At the medical centre, the deceased got out of the wheelchair, walked inside and got onto the examination bed unaided. She was given Mylanta for her reported indigestion as well as oxygen and aspirin. The deceasedâ€™s blood pressure and oxygen saturations were taken and an electrocardiogram (ECG) was performed. At about 6.35 pm, the deceased suddenly reported severe chest pain and said she felt as if she was going to die. She was noted to be very clammy, cold and a bit grey and her ECG was noted to be abnormal. Nursing staff suspected the deceased was having a heart attack and arranged to transfer the deceased by ambulance to Royal Perth Hospital (RPH), the closest hospital with specialist cardiac facilities.
The Officer in Charge of the Prison facilitated the entry of the ambulance and arrange custodial officers to accompany the deceased to hospital. Ambulance officers received a handover from the prison nurses and performed an ECG which they attempted to transmit to RPH. The transmission was not received and was successfully resent. The deceasedâ€™s ECG indicated she was having a heart attack and anticoagulant medication ambulance officers were ordered to give her anti-coagulant medication. As they were about to leave the Prison, the deceased had a VF arrest. Ambulance officers successfully revived the deceased and rushed her to RPH. The deceased was critically unwell when she arrived at RPH. The deceased was initially conscious when she arrived at RPH, but was critically unwell. She had further VF arrests and despite the considerable efforts of the cardiac catheter team, the deceased could not be revived and she was declared deceased at 9.18Â pm on 10 December 2016.
In general terms, the Coroner was satisfied that the quality of supervision, treatment and care provided to the deceased during her incarceration was appropriate. However, the Coroner commented that changes made (and about to be made) to health service delivery by the Department were appropriate. Although not causative of the deceasedâ€™s death, the Coroner also noted that the Prisonâ€™s medical centre, which has been described as â€˜not fit for purposeâ€™ should be remediated.
Catch Words: Death in Custody : Prison Medical Centre : Overcrowding : Womenâ€™s Prison : Natural Causes.
Report: Judy Sonia BOLTON