Inquest into the death of Steven Andrew Forbes

Contributing factors

• chronic rheumatic heart disease with mitral and aortic valve damage
• loss of prescribed antibiotic medication (Dicloxacillin) during custody intake
• inadequate prison reception assessment despite documentation of recent hospitalization and reported poor health
• failure to call on-call nurse despite presentation with respiratory distress, fever, cough, and recent surgery
• delayed doctor's appointment (scheduled 3 days post-reception rather than next day)
• reliance on prisoner self-reporting in reception interview without verification against medical records
• lack of clear protocols for medication handling and escalation of care in custodial setting

Coroner's recommendations

1. Northern Territory Police Service develop and implement a policy addressing the receipt, custody and administration of prisoners' prescribed medications
2. Correctional Services develop and implement a policy as to the use of on-call nurses to guide prison officers' discretion in escalating care
3. Prison staff be made aware that court return assessments are brief and focus on mental health, not comprehensive physical health assessment, and should not be relied upon as justifying delay in responding to signs of acute physical illness
4. Prison reception procedures include verification of key facts (such as prior custody history) against records rather than relying solely on prisoner self-reporting
5. Medical assessment of newly received prisoners occur within 24 hours, not several days post-reception, particularly when prisoner reports recent hospitalization and current poor health