Inquest into the death of Paigh Bartholomew
Deceased
Paigh Bartholomew
Demographics
21y, female
Date of death
2012-06-16
Finding date
2017-07-25
Cause of death
mixed heroin and alprazolam toxicity
AI-generated summary
Paigh Bartholomew, 21-year-old Aboriginal woman, died from mixed heroin and alprazolam toxicity in a minimum-security correctional centre following systemic failures. She had been placed in a minimum-security facility despite being found in possession of significant drug quantities at maximum-security Silverwater, where staff failed to follow procedures for reporting suspected contraband to police. At Emu Plains, an intelligence officer identified drug delivery plans but was unavailable on the critical dates to intercept them. Security officers failed to conduct required perimeter checks on the night of drug delivery, missing evidence of a compromised window. Inmates who witnessed Paigh's apparent overdose were intimidated from seeking help via the duress alarm. Clinical lessons include the importance of institutional communication protocols, continuity of care monitoring, and ensuring visible clinical deterioration triggers emergency intervention.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to follow procedures for reporting suspected contraband at Silverwater, allowing progression to minimum-security facility
- Absence of intelligence officer coverage on 14-15 June 2012, preventing interception of planned drug delivery
- Failure by correctional officers to conduct required perimeter security checks on night of 15-16 June 2012
- Failure to detect compromised window security due to non-completion of sterile zone checks
- Intimidation of inmates preventing use of duress alarm to call for medical assistance
- Lack of staff training in identifying novel drug preparations
- Absence of replacement or handover procedures for intelligence officer duties
Coroner's recommendations
- Induction process for new inmates at Emu Plains Correctional Centre should specifically note the presence of the duress alarm within each house, that pressing it will alert staff at Administration Centre, and that it will not cause an alarm or light to sound/flash within or around the house
- Commissioner of Corrective Services should approach Commissioner of NSW Police Force to request update briefings on current concealment methods and packaging for heroin to assist in detecting contraband and training Corrective Services staff
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