Inquest into the death of Michael Baker

Contributing factors

• Inadequate blood pressure monitoring despite explicit clinical directions
• Failure to refer for obstructive sleep apnoea testing due to clerical error with no subsequent follow-up
• Absence of follow-up after serious seizure-like episode and hospitalisation in April 2019
• Failure to perform ECGs after medication changes in October 2018 and May 2019
• Incomplete diabetes management including missed eye checks, foot checks, and specialist referrals
• Non-implementation of multiple clinical referrals and recommendations documented in clinical notes
• Inadequate attention to chronic pain and footwear issues despite repeated patient requests
• Severe under-resourcing of custodial health service with insufficient staffing
• Single general practitioner attending one day per week for six hours to serve 400-420 inmates
• Overwhelming nursing workload leading to non-completion of clinical tasks and failure to record observations

Coroner's recommendations

1. Justice Health to continue giving close consideration to identifying sleep apnoea in inmates and to testing inmates on large daily doses of methadone (>50mg) given the significant damage sleep apnoea can cause to cardiac health
2. Justice Health and Ministers to carefully consider the staffing position at Lithgow Correctional Centre (currently one GP attending once per week for six hours) and take necessary steps to ensure appropriate levels of care can be provided to all inmates
3. Ongoing consideration to be given to how to appropriately audit or provide oversight of the failure to enter records, which might require on-the-spot checking by Nurse Unit Managers or co-workers
4. Justice Health to continue encouraging staff education and auditing in relation to record keeping (SAGO charts) on an ongoing basis
5. Copy of findings to be provided to NSW Commissioner of Corrective Services, NSW Minister for Corrections, NSW Minister for Health and Regional Health, Federal Minister for Health and Aged Care, NSW Minister for Aboriginal Affairs and Treaty, and Federal Minister for Indigenous Australians