Inquest into the death of Nathan REYNOLDS

Contributing factors

• deficiencies in management of severe asthma by Justice Health and Forensic Mental Health Network
• deficiencies in immediate response to medical emergency by Corrective Services NSW
• delayed response by correctional officers to knock-up call (11 minutes)
• delayed notification of night nurse (13 minutes)
• delayed arrival of night nurse (22 minutes)
• delayed ambulance call-out (18 minutes after initial call for help)
• failure to perform Chronic Disease Screen while in custody
• absence of Asthma Action Plan
• inadequate ongoing asthma management in custody
• rigid procedures requiring three officers before seeking medical assistance
• lack of urgency in officer response
• night nurse stationed off-site at another facility
• frequent Ventolin dispensing not identified as red flag for uncontrolled asthma
• inadequate clinician awareness of Chronic Disease Screening requirements
• no specialist respiratory review despite severe asthma history
• respiratory deterioration triggered by preceding cold and flu-like symptoms

Coroner's recommendations

1. CSNSW review its practice, procedures and instructions to COs regarding response to serious health events including asthma attacks, with training on how to identify such events and instruction that events may be life-threatening until proven otherwise, with specific reference to lessons from Nathan's death
2. CSNSW review role of senior CO in responding to suspected serious health events, including immediately deciding whether to request nurse or paramedic before CO sights inmate
3. CSNSW provide CO training on asthma including risks, identifying elevated-risk indicators (regular puffer use, cold/flu symptoms), and including asthma as significant health condition in policy
4. CSNSW review staffing arrangements to ensure sufficient COs on duty for immediate response to serious health events and ensure rostered COs are sufficiently fit to respond urgently
5. JH Network review practices for asthma management including clinician education on severe asthma identification and risks, templates specific to custodial environment, telehealth specialist review arrangements, and development of custodial-specific Asthma Action Plan templates
6. JH Network investigate Winnunga Nimmityjah Aboriginal Health and Community Services model of care for First Nations prisoners and consider implementation of relevant features
7. JH Network review adequacy of nursing rostering where nurse not based overnight at correctional centre
8. JH Network ensure all first aid trolleys used for serious health events at night have defibrillator at all times
9. JH Network review Chronic Disease Screening and asthma management protocols to ensure specialist diagnosis of severe asthma and appropriate management plans with regular monitoring and reviews
10. JH Network review whether registered nurses can administer intramuscular adrenaline in emergency situations
11. JH Network update Adult Emergency Response Guidelines for acute asthma with specific guidance on referral to Chronic Disease Screening and Asthma Action Plan development
12. CSNSW and JH Network review communication arrangements between senior COs and registered nurses to enable immediate, continuous real-time communication
13. CSNSW and JH Network provide joint scenario training to COs and registered nurses in managing medical emergencies and providing first aid in open minimum security environments