Coronial
NSWhospital

Inquest into the death of Ian Davidson

Demographics

84y, male

Date of death

2016-05-14

Finding date

2018-07-18

Cause of death

Complications of hypertensive and atherosclerotic cardiovascular disease

AI-generated summary

An 84-year-old prisoner with multiple chronic conditions (hypertensive and atherosclerotic cardiovascular disease, diabetes, hepatitis B, previous bowel cancer, heart failure) suffered a fatal cardiac arrest whilst attempting to board a standard prison transport truck despite being assessed as requiring special transport via van. The coroner found death resulted from natural cardiovascular causes. Communication failures prevented the transport modification recommendation from reaching security staff, though the coroner determined no action could have prevented the death. Systemic improvements were identified: protocols for alerting staff about special transport needs, OIMS system updates, and hospital procedures for managing deceased persons' medical equipment in coronial cases. Healthcare and custodial care were deemed appropriate throughout.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

cardiologyemergency medicineforensic medicinegeriatric medicine

Error types

communicationsystem

Drugs involved

fentanylinsulincardiac medicationsmedications for heart failure

Clinical conditions

hypertensive and atherosclerotic cardiovascular diseasecardiogenic shock due to ischaemic cardiomyopathyprevious heart failurediabetes mellitushepatitis bbowel cancercardiac arrest

Procedures

defibrillationcardiopulmonary resuscitationblood testchest X-raybrain CT scanintravenous linesfentanyl syringe administration

Contributing factors

  • transport by standard prison truck rather than van despite medical assessment recommending alternative transport
  • communication breakdown between Justice Health and Court Escort Security Unit regarding special transport requirements
  • physical exertion during boarding of truck in context of advanced frailty and cardiac disease
  • cardiac collapse during attempted boarding of truck

Coroner's recommendations

  1. Implementation of new protocols requiring Justice Health to issue medical certificates for special transport needs
  2. Requirement for Court Escort Security Unit Coordinator to update computerised Offender Integrated Management System (OIMS) with alerts for special transport needs
  3. Creation of Special Transport Packages including Special Transport Arrangements Form, checklist, medical certificate and OIMS alert
  4. Requirement for Correctional Officers in charge of prisoner transport to check OIMS for special instructions prior to transport
  5. Westmead Hospital to ensure medical equipment on deceased persons' bodies is left in situ for coronial cases
  6. Westmead Hospital Emergency Department newsletter and training resources updated to reinforce requirements for care of deceased in coronial cases
  7. Westmead Hospital 'Care of the Deceased' Resource Folders updated and distributed to all units
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