Inquest into the death of Daniel Phillips Johnson
Deceased
Daniel Phillips Inging Johnson
Demographics
33y, male
Date of death
2010-08-11
Finding date
2011-11-18
Cause of death
acute hydrocephalus following ventricular blockage by a colloid cyst
AI-generated summary
Daniel Johnson, a 33-year-old Aboriginal man, died of acute hydrocephalus caused by a colloid cyst in the brain while in custody at Darwin Correctional Centre. He had complained of severe, recurring headaches for months before his fatal seizure. The coroner found that while the cause of death was natural and not necessarily negligent, there was a failure to escalate medical response to his complaints. Key failures included: incomplete documentation of headaches in medical records, a breakdown in communication between prison officers and nurses, unavailability of a CT scan despite appropriate indications, and poor integration of information from a separate Panadol register into clinical decision-making. The coroner concluded that if the cyst had been detected via imaging, timely intervention might have saved his life, though survival was not guaranteed.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to escalate medical response to recurring severe headaches
- incomplete documentation of headache complaints in medical records
- panadol register not integrated into electronic medical records
- medical staff did not review complete medical history at appointments
- failure to book specialist consultation requested by prison doctor
- lack of communication between medical staff and prison officers about deterioration
- no guidelines for prison officers to contact on-call nurse
- bulky physical medical files and cumbersome electronic record access
Coroner's recommendations
- That Correctional Services develop and implement a policy as to the use of on-call nurses to assist prison officers in the exercise of discretion about contacting nurses when a prisoner's condition changes
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