Inquest into the death of Ivan Goolagong

Contributing factors

• Failure to comply with Crimes (Administration of Sentences) Regulation cl. 285 requiring notification of terminal illness
• Lack of timely palliative care referral and engagement
• Absence of care coordination despite terminal diagnosis
• Lack of culturally-appropriate care for Aboriginal patient
• Inadequate support for family engagement in early-release process
• Inadequate nutritional support and weight management
• Failure to facilitate phone contact with family in final hours
• Miscommunication regarding cancer diagnosis and disease progression
• No involvement of Cancer Care Nurse Coordinator despite mandatory requirement
• Lack of Aboriginal health worker support and cultural brokering
• Silo'd services between CSNSW and Justice Health
• Delayed referral to community palliative care team
• Misinformation provided to family about early-release application process

Coroner's recommendations

1. CSNSW develop a policy to guide Services and Programs Officers, Regional Aboriginal Programs Officers, psychologists and other relevant staff in advising and assisting inmates seeking early release on medical grounds, aimed at facilitating applications without requiring legal assistance
2. CSNSW take interim action to ensure relevant staff are aware of the need to expedite early release applications, can contact CSNSW project officers for advice, and understand such applications do not require legal assistance
3. CSNSW and Justice Health formalise a policy to help inmates with terminal illness and their families apply for early release in a manner minimising delay and not requiring external legal representation to obtain medical reports
4. Justice Health ensure staff with reporting obligations under cl. 285 CAS Regulation are aware of their obligations
5. CSNSW and Justice Health establish a working party to develop practices ensuring terminally ill inmates in the MSU have phone access to family at any hour, with streamlined clinical staff authority to facilitate calls without requiring CSNSW permission
6. CSNSW and Justice Health review Associate Professor Megan Williams' report and consider implementing policy suggestions for palliative care of First Nations prisoners
7. CSNSW and Justice Health working party consult with Associate Professor Williams to consider peer support programs for terminally ill First Nations prisoners and in-reach services from community-based First Nations health organisations
8. CSNSW provide greater support for and increase numbers of Regional Aboriginal Programs Officers and Aboriginal Support and Programs Officers to reflect proportion of First Nations inmates in NSW
9. Justice Health employ at least two First Nations health care workers, nurses or medical officers as part of MSU clinical staff and ensure adequate support for their effectiveness
10. MSU clinical staff receive immersive training in provision of health care to First Nations patients within First Nations community health organisation settings
11. Justice Health develop a care planning protocol for all MSU patients with terminal illness diagnoses, with clear multi-disciplinary plans devised, followed up and regularly re-evaluated
12. Positions responsible for devising, overseeing and evaluating care plans be clearly identified and known by MSU clinical staff
13. Role and responsibilities of Cancer Care Nurse Coordinator relating to MSU patients be clearly delineated, made known to clinical staff and audited for effectiveness
14. Justice Health urgently prioritise immersive training for MSU clinical staff involving placements with outside palliative care providers such as PEPA (Program of Excellence in the Palliative Approach)
15. Further training of MSU staff in palliative care emphasise importance of early identification of psychosocial needs and skills in rapport development