Inquest into the death of Sampson Paii

Contributing factors

• failure to communicate prison officer's clinical observations to treating doctor
• failure to order broader diagnostic testing when initial investigations were normal
• delayed response to acute deterioration in prison
• inadequate prison medical screening on admission to detect underlying pathology
• limited backup and support for junior medical officer in prison setting

Coroner's recommendations

1. Prison communications officers should ascertain basic information about the nature and severity of medical emergencies when alert buttons are pressed, not just the prisoner's name and that they are 'sick'
2. Prison authorities should establish systems to improve response times to emergency alerts
3. Prison monitoring systems should be regularly checked for accuracy of time recording
4. Prison officers should receive training in use of Oxyviva oxygen equipment for use during after-hours when medical professionals are not present
5. Prison authorities should examine tender requirements for nursing staff to ensure adequate levels to prevent communication problems between doctors and nurses
6. Consideration should be given to provision of Aboriginal health workers to assist nurses given cultural sensitivities and communication barriers affecting Aboriginal prisoners
7. Prison authorities should review medical evidence and expert reports to assess what health checks and tests are appropriate on admission to prison, in consultation with NT Department of Health and Community Services