Inquest into the death of Ronald BRIZZOLARA
Deceased
Ronald James Brizzolara
Demographics
60y, male
Date of death
2014-10-25
Finding date
2017-03-17
Cause of death
Congestive Cardiac Failure
AI-generated summary
A 60-year-old Aboriginal man with end-stage COPD, congestive cardiac failure, and ischaemic heart disease died in prison custody. He likely suffered cardiac collapse around 8:30-9:00pm on 25 October 2014, pressed his cell alarm seeking help, but the alarm network had failed due to a UPS power supply fault that occurred 24 hours earlier. The alarm light illuminated in his cell but did not relay to staff at other locations. A neighbouring inmate heard banging and activated his alarm, which also failed to reach staff. Mr Brizzolara was found deceased at 11:12pm. He had agreed to a 'no CPR' order given his poor prognosis. The death was caused by natural cardiac disease and was not preventable; however, systemic failures in monitoring the cell alarm network meant his distress call went unheeded for several hours. Corrective Services implemented improvements to alarm monitoring, redundancy, and network fault detection.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- End-stage Chronic Obstructive Pulmonary Disease
- Ischaemic heart disease
- Obesity
- Cell call alarm network failure due to UPS power supply fault
- Failure of alarm relay system to alert staff to network failure
- Delayed response to inmate distress signals
- System masking of alarm failure due to concurrent network maintenance
Coroner's recommendations
- Cell call alarm network failures now trigger high-pitched alarm in Night Senior's office, Gatehouse and Complex monitor room that continues until manually cancelled
- System monitors now display all network errors in sequence with location descriptions to enable identification of new errors
- Cell alarm relayed to Night Senior's office after 10 seconds (reduced from 30 seconds) and continues at each subsequent location until answered
- Staff training on identification and response to network faults
- Equipment room locks changed and access restricted
- Changes communicated to other gaols operating the same cell call alarm system
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