Inquest into the death of Danny Whitton

Contributing factors

• Failure to action blood tests ordered on 6 November 2015
• Inadequate vital sign monitoring and documentation
• Absence of proper Standard Adult General Observation chart
• Poor nursing record keeping and clinical notes
• Failure to repeat urinalysis testing despite abnormal results on 5 November
• Inadequate assessment of abnormal urinalysis findings (blood, protein, likely bilirubin)
• Misunderstanding of patient transfer protocols by nursing staff
• Delayed recognition of clinical deterioration on 7 November
• Delay in calling ambulance on morning of 7 November
• Doctor not attending until afternoon despite reported deterioration
• Doctor's advice to 'wait and see' despite GCS 11
• Inadequate or absent clinical observations during night shift 5-6 November
• Improper use of GEO Intelligence urinalysis for correctional purposes
• Disclosure of health information to Intelligence without proper consent
• Prisoner's fear of punitive response for disclosing drug ingestion history
• Limited access to Opiate Substitution Treatment program
• Widespread availability and stockpiling of paracetamol by prisoners
• Poor lighting and CCTV-only monitoring in medical ward
• Systemic failures in blood testing collection and documentation system
• Lack of standard handover protocols between nursing shifts

Coroner's recommendations

1. GEO Group Australia Pty Ltd: Ensure training occurs so all health staff are aware nurses can call ambulance to transfer prisoner without doctor's authorisation
2. GEO Group Australia Pty Ltd: Ensure health service policy accurately reflects importance of regular monitoring, notation, recognition of deterioration signs and clear escalation procedures at Junee Correctional Centre health clinic
3. GEO Group Australia Pty Ltd: Provide training to health and corrections staff about permissible collection, use and disclosure of health information
4. Justice Health and Mental Health Forensic Network: Provide training identifying and raising awareness that paracetamol overdose can occur from excessive consumption
5. Justice Health and Mental Health Forensic Network: Develop information sheet for health and correctional staff to prompt inquiry about quantity of paracetamol ingested and provide pathways for staff regarding any paracetamol overdose
6. Justice Health and Mental Health Forensic Network: Conduct review of Paracetamol Consumer Medicines Information to include warning about misuse or overdose, risk of harm, possible symptoms and indication of when to seek medical attention
7. Corrective Services NSW and privately operated correctional centres including GEO: Provide training identifying and raising awareness that paracetamol overdose can occur from excessive consumption
8. Corrective Services NSW and privately operated correctional centres including GEO: Provide information to inmates identifying and raising awareness that paracetamol overdose can occur from excessive consumption
9. Corrective Services NSW and privately operated correctional centres including GEO: Implement policy and practice to retain copy of CCTV footage capturing last 7 days of movements of person who died in custody and only release upon coroner indication that footage no longer required