Inquest into the death of DP

Contributing factors

• untreated severe obstructive sleep apnoea lasting over 9 months
• depression not responsive to antidepressant monotherapy without psychiatric review
• lack of psychiatric referral despite failed initial treatment and complex psychiatric history
• failure to identify that patient had only trialling prescription, not formal CPAP prescription
• system delay in obtaining specialist respiratory review (9+ months)
• inadequate morning cell check procedures on public holiday
• absence of collateral psychiatric history gathering
• patient frustration with self-referral form system
• serious criminal charges and uncertainty about lengthy incarceration

Coroner's recommendations

1. St Vincent's Correctional Health should formalise a policy for acquiring CPAP machines for inmates who require them in custody, including the source and funding of those machines
2. St Vincent's Correctional Health should consider enhancing the system of patient self-referral at Parklea Correctional Centre, to include access to appointments via telephone
3. The Commissioner Corrective Services NSW should continue to seek additional funding for the program of cell refurbishment, to progress the removal of obvious ligature points from cells in correctional centres as a matter of urgency