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, with contributing conditions of coronary artery disease, diabetes mellitus type 1, and Crohn's disease
AI-generated summary
Ms Vicki Higgins, a 48-year-old woman with diabetes, Crohn's disease (requiring ileostomy), and coronary artery disease, died from ischaemic bowel while in custody at Junee Correctional Centre on 29 January 2022, only 17 days after admission. She was never medically screened despite being received during an unprecedented COVID-19 outbreak causing severe staff shortages. Throughout her custody, she reported nausea, vomiting, inability to eat or drink, and requested hospital transfer on multiple occasions. Expert evidence confirmed inadequate care: she should have been screened at reception and transferred to hospital. While hospitalisation may not have prevented death given the extent of bowel ischaemia, it would have provided comfort, pain relief, and palliative care. The coroner found systemic failures including failure to complete reception screening, inadequate medical assessment by the sole available doctor (seen only day before death under time pressure for self-harm screening, not medical assessment), and failure to escalate her deteriorating condition. Staff shortages and COVID protocols contributed but did not excuse the failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- failure to complete reception medical screening within 24 hours of admission
- failure to perform second COVID-19 swab on day 12 as required by protocol
- inadequate medical assessment by doctor who saw patient only day before death under time pressure for self-harm screening rather than comprehensive medical evaluation
- failure to escalate deteriorating patient condition despite 17 days of documented symptoms including nausea, vomiting, inability to eat or drink, and repeated requests for hospital transfer
- COVID-19 outbreak causing unprecedented staff shortages and reduction of nursing staff from 13 to 5
- isolation of sole attending doctor (Dr C.) from 16-27 January 2022 with no medical officer replacement
- inadequate communication between correctional officers and control room regarding urgent medical calls
- failure to call ambulance despite multiple requests from patient and another inmate on morning of death
- failure to conduct proper vital signs and physical examination during custody despite frequent nursing contact
Coroner's recommendations
- Corrective Services NSW record information conveyed to correctional officers from the control room directing the correctional officer to attend to respond to an urgent cell call from an inmate for medical attention
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