Walker, Nola Jean

Contributing factors

• Failure to recognise concealed splenic and thoracic injuries at initial ambulance assessment
• Severe intoxication masking symptoms of internal injuries
• Combination of alcohol and diazepam causing sedation that mimicked simple drunkenness
• Rapid progression of hypovolaemic shock attributable to splenic injury
• Failure of police officers to monitor for deterioration in detainee's condition
• Police not informed by ambulance service of potential for concealed injuries
• Lack of escalation to medical assessment despite progressive deterioration in custody
• Failure to initiate CPR in timely manner

Coroner's recommendations

1. QPS and QAS should consider ways of ensuring that information relevant to the health and safety of patients/prisoners is passed between the services, including informal communication about potential adverse developments in trauma cases
2. QPS should review training materials and Operational Procedures Manual provisions to draw together and reinforce medical issues associated with intoxicated and apparently intoxicated persons, including: not assuming intoxication when other conditions mimic it; being alert for indications of conditions that mask intoxication; recognising that increasing vagueness and lethargy over time warrants review; and recognising concealed haemorrhage as a cause of deterioration
3. Police should be reminded of obligations under OPM 16.24.2(iii) to attempt resuscitation when finding an apparently dead prisoner if appropriate
4. Training materials should ensure that assessment of prisoners includes thorough observations (temperature, breathing, pallor) and not just distant visual checks, applicable to all places of custody including holding rooms