Inquest into the death of Jeremy aka Lawrence Tunkin
Deceased
Jeremy Tunkin (aka Lawrence Tunkin)
Demographics
39y, male
Date of death
2017-08-08
Finding date
2018-11-26
Cause of death
acute myocardial ischaemia, coronary artery thrombosis and coronary artery atherosclerosis
AI-generated summary
Jeremy Tunkin, an Aboriginal man with severe hearing loss, died of acute myocardial infarction while in prison custody. On 6 August 2017, he presented to the medical clinic with what prisoners identified as chest pain, but staff interpreted as throat or shoulder complaints. Communication difficulties due to his deafness likely contributed to misidentification of his complaint. He was discharged after normal observations and returned to his cell. Two days later, he collapsed and died. The coroner found no criticism of the care provided but identified communication barriers as a significant issue. Key lessons: healthcare staff must recognise that cardiac pain can present atypically and be referred to the neck/throat area; heightened vigilance is needed for hearing-impaired patients; appropriate interpreter use and electronic information-sharing between medical and custodial systems are essential to avoid missing critical clinical information.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- communication difficulties with hearing-impaired prisoner
- staff misinterpretation of patient complaint (chest pain described as throat/shoulder pain)
- absence of formal hearing loss protocol at correctional centre
- incomplete interpreter use despite communication barriers
- lack of information sharing between medical and correctional records
- failure to recognise atypical presentation of cardiac pain
- underestimation of cardiac risk despite prior chest pain presentation
Coroner's recommendations
- Maintain register of clients with specific or complex care needs and ensure availability to regular and agency staff
- Provide staff training on identifying and accessing appropriate interpreter services with documentation and monitoring at system level
- Provide better policy guidance for managing clients with combined hearing and speech difficulties and integrate with offender management plan
- Develop information sharing protocol between CAHS, NT Corrections and Police to ensure communication of key health information at point of entry to ASCC
- Employ an Aboriginal Health Practitioner at ASCC healthcare centre
- Ensure contact with usual clinic for new longer-stay patients to obtain medical summary for medical records
- Investigate optimal use of telehealth at ASCC to improve access to and quality of care
Full text
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