Inquest into the death of Mr Dooley

Contributing factors

• Failure to recognise abnormal ECG in June 2019 and refer to cardiology despite high cardiovascular risk
• Failure to properly interpret and escalate abnormal ECG of 13 September 2022
• Delayed recall for cardiology review (13 days late)
• Incomplete communication regarding health complaint on 25 September 2022
• Failure to take full vital observations on 26 September 2022
• Failure to recognise acute coronary syndrome presentation
• Inadequate monitoring in Medical Housing Unit
• Hyperlipidaemia not adequately managed in custody
• Non-adherence with statin therapy

Coroner's recommendations

1. Clear guidelines/procedures for appropriate ECG management, review, and referral in Prison Health
2. Clear guidelines/procedures for managing PCIS recall system to ensure timely recall including identification and actioning of high priority recalls
3. Medical Housing Prison Health Guideline to address responsibility for CCTV monitoring, intercom responses, and nurse station coverage
4. Review Non-Clinical Triage PPHC Remote Form, Nurse and Manager On-Call Prison Health Procedure, and Prison Health Triage Codes for consistency, clarity, and provision for direct client communication and 'closing the loop'
5. NT Health to offer interpreters, Aboriginal Health Workers and Aboriginal Liaison Officers to Aboriginal families in death in custody communications
6. Policy/procedure ensuring direct telephone or video communication between prisoners and medical staff for health complaints
7. Review process for recording medical information in SCATE and IRNA forms to ensure accuracy
8. Review current prison diet to conform to Australian Dietary Guidelines and address suitability for prisoners with high cholesterol/cardiac risks
9. Review policies and training on documentation of prisoner medical incidents
10. Improved supervision and guidance for police investigating reportable deaths to ensure thorough investigations per policy