Coronial
NSWprison

Inquest into the death of Dushyanthan Visvanathan

Deceased

Dushyanthan Visvanathan

Demographics

55y, male

Coroner

Decision ofDeputy State Coroner O'Neil

Date of death

2019-09-26

Finding date

2025-09-05

Cause of death

Complications of alcohol use disorder

AI-generated summary

Dushyanthan Visvanathan, a 55-year-old man with alcohol use disorder and prior withdrawal seizure, died in custody at MRRC from complications of alcohol use disorder. Critical failures in clinical care included: inadequate recording of observation frequency by the medical officer; failure to document vital signs appropriately; insufficient monitoring (only two sets of vital observations in 10 hours overnight); placement in a cell 100 metres from nursing staff despite requiring medical observation; and lack of clear communication to correctional officers regarding monitoring requirements. While the death resulted from sudden cardiac arrest secondary to alcoholic ketoacidosis (unwitnessable), proper four-hourly vital sign monitoring with additional checks between observations was not implemented. The coroner found the nursing staff's failings (incomplete reception assessment, inadequate documentation, misunderstanding of cell placement terminology, and inappropriate gross observations as substitutes for vital signs) fell short of expected standards, though causation could not be established. Systemic issues in policy clarity and workload pressures were noted.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

addiction medicineemergency medicinegeneral practicecorrectional healthcardiology

Error types

communicationdocumentationsystem

Drugs involved

diazepam

Clinical conditions

alcohol use disorderalcohol withdrawalalcoholic ketoacidosissudden cardiac deathhypertensionprior subdural haemorrhagedepression and anxiety

Procedures

cardiopulmonary resuscitationguedel airway insertionoxygen mask application

Contributing factors

  • Inadequate recording of medical observation frequency by ROAMS doctor
  • Failure to record frequency of observations in clinical notes by nursing staff
  • Insufficient frequency of vital sign monitoring overnight (only at 8pm and midnight)
  • Inappropriate cell placement (100 metres from medical staff) despite need for medical observation
  • Failure to specify appropriate cell type (camera cell) in Health Problem Notification Form
  • Lack of clear communication to correctional officers regarding observation requirements
  • Misunderstanding by nursing staff of cell placement terminology
  • Gross observations performed instead of proper vital signs assessment at 1:51am
  • Alcoholic ketoacidosis (underlying pathophysiology)
  • Cardiac complications of chronic alcohol use
  • Hypertension and prior subdural haemorrhage

Coroner's recommendations

  1. That the drug and alcohol substance withdrawal monitoring form used by Justice Health be amended to incorporate, firstly, guidance regarding the frequency of observations recommended for patients in alcohol withdrawal, and secondly, a field which can be used by practitioners to indicate the plan for the frequency of observations for the patient
  2. That consideration be given to sending out or publishing a short communication to Justice Health staff which emphasises the importance of proper ventilation during CPR
  3. Consideration be given to seeking an allocation of funding from the Ministry of Health, for the staffing of drug and alcohol remote offsite and after-hours medical service shifts until 11pm with an on-call service to continue to be provided from 11pm onwards
Full text
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Source and disclaimer

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