Inquest into the death of Hector Martin

Contributing factors

• Cirrhosis of the liver from chronic alcoholism
• Inadequate monitoring system using non-medically trained prison officers
• Failure to escalate repeated vomiting to medical staff
• Failure to recognise and respond to patient's requests for medical assistance
• Patient symptoms of headache and dizziness not communicated to medical staff
• Unclear role of prison officers regarding physical health deterioration
• Patient lay unresponsive for several hours before discovery
• Lack of clear communication between medical and custodial staff about observation protocols

Coroner's recommendations

1. Medical observations of physically ill prisoners should be conducted by medically trained nursing staff, not by non-medically trained prison officers using camera surveillance
2. Prison officers and medical staff need clearer communication and defined roles regarding what constitutes medical deterioration requiring escalation
3. Clear information about prisoners' medical conditions and risks should be communicated to supervising officers to guide appropriate escalation decisions
4. Consideration of extending revised observation protocols to prisoners at risk due to mental health status, with attention to balancing confidentiality with safety
5. The system implemented in December 2005 (nurses observing 'at risk' prisoners in the clinic) is more appropriate than camera surveillance by untrained officers