Coronial
NSWother

Inquest into the death of Eric WHITTAKER

Deceased

Eric Whittaker

Demographics

35y, male

Date of death

2017-07-04

Finding date

2020-02-28

Cause of death

subarachnoid haemorrhage with antecedent ruptured cerebral artery aneurysm

AI-generated summary

Eric Whittaker, a 35-year-old Aboriginal man, died from a subarachnoid haemorrhage caused by a ruptured cerebral artery aneurysm while in remand custody at Parklea Correctional Centre. On 2 July 2017, he made 20 emergency 'knock-up' calls over three hours expressing extreme distress, confusion, hyperventilation and claustrophobia, but correctional officers failed to recognise these as signs of medical emergency. Eric was not seen by clinic staff until 8:00am—three vital hours later. By then, he was incontinent, vomiting, and profoundly unwell. Medical staff at hospitals later recognised a ruptured aneurysm, but it was too late to prevent catastrophic brain injury and death. The coroner found the delay in medical assessment 'disgraceful'. Officers required training to recognise signs of acute medical distress and escalate appropriately rather than dismissing distressed inmates as emotionally distressed. Policy changes have since been implemented requiring immediate welfare checks and medical review when inmates present with emotional, distressed or disoriented presentations.

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

Specialties

correctional healthneurologyemergency medicineintensive caretoxicology

Error types

diagnosticcommunicationsystemdelay

Drugs involved

amphetamineheroinhaloperidolmetoclopramidedroperidolpropofolbenzodiazepines

Clinical conditions

ruptured cerebral artery aneurysmsubarachnoid haemorrhageacute agitationhyperventilationhypoxic ischaemic brain injurysubstance use disorderdepressionanxiety

Contributing factors

  • failure of correctional officers to recognise medical emergency
  • delayed transfer to medical clinic
  • failure to escalate repeated distress calls to senior staff
  • inadequate training of correctional officers in recognising acute medical presentations
  • failure to conduct welfare checks despite 20 knock-up calls over 3 hours
  • possible amphetamine ingestion increasing blood pressure and aneurysm rupture risk
  • three-hour delay in medical assessment from first call to clinic attendance

Coroner's recommendations

  1. GEO Group amended the Stenofon Policy (OP065) on 1 September 2017 to require Control Room Operators to immediately initiate a welfare check and advise their manager/supervisor when an inmate is presenting in a clearly emotional, distressed, or disoriented state
  2. Control Room Operator training package to be reviewed to provide adequate instruction on how to respond to and report cell alarm calls from inmates who are clearly distressed, disoriented, or apparently intoxicated
  3. CMO to attend the Upper Control Area at least twice during night shift to consult with Control Room Operators and review logs/journals
  4. CSNSW Guarding Inmate Patients policy implemented requiring: all handcuffs removed at request of health professionals during consultation/examination/treatment; handcuffs may be removed from severely incapacitated inmates; review of escort assessment when circumstances change; consideration of end-of-life care arrangements including family visiting
  5. Correctional officers require training in recognising signs of acute medical distress and mental health issues
  6. Correctional officers require training in appropriate use of restraints, removal of restraints when medically indicated, and sensitivity to family distress
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