Inquest into the death of Vicki Higgins
Deceased
Vicki Higgins
Demographics
48y, female
Date of death
2022-01-29
Finding date
2024-05-17
Cause of death
Ischaemic bowel; coronary artery disease, diabetes mellitus and Crohn's disease were significant contributing conditions
AI-generated summary
Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (with prior colectomy and ileostomy), and coronary artery disease, died from ischaemic bowel on day 17 of incarceration at Junee Correctional Centre during a severe COVID-19 outbreak. She was never medically screened despite being placed on high-risk protocols. Over 17 days, she repeatedly reported nausea, vomiting, inability to eat/drink, and requested hospital transfer. Nursing staff documented these symptoms on eight occasions but care was never escalated. Expert evidence confirmed inadequate care; both a gastroenterologist and GP stated she warranted hospital transfer despite uncertainty whether this would have prevented death. The coroner found the failure to perform reception screening was a significant missed opportunity and breach of guidelines. While the unprecedented COVID outbreak contributed to staff shortages, the systemic failures in assessment, escalation, and responsiveness were critical deficiencies.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- failure to perform reception medical screening
- failure to escalate care despite 17 days of reported symptoms
- failure to transfer to hospital despite repeated requests
- inadequate assessment by doctor (HRAT screen only, not medical assessment)
- reduced medical staffing due to COVID-19 outbreak
- COVID-19 isolation protocols limiting contact
- incomplete documentation of nursing assessments
- failure to perform second COVID swab on due date
- reliance on informal reports from correctional officers rather than direct medical assessment
Coroner's recommendations
- Corrective Services NSW should record information conveyed to correctional officers from the control room directing officers to respond to urgent cell calls from inmates for medical attention, to ensure officers are informed of the nature and urgency of the call
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Source and disclaimer
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