Clumpoint, Thomas Andrew

Contributing factors

• Residual squamous cell carcinoma infiltrating pharynx, larynx, and perilaryngeal tissues
• Severe laryngeal oedema causing critical airway narrowing
• Defective cell intercom system not repaired promptly
• Initial emergency call garbled and not properly understood by control room staff
• Delayed code blue activation
• Lack of contingency planning for medical emergencies in custodial setting
• Absence of procedures for handling inaudible or garbled intercom calls
• Insufficient documentation and monitoring of intercom faults

Coroner's recommendations

1. QCS review, research, design and implement a comprehensive documented state-wide regime for the maintenance and testing of cell intercoms
2. QCS ensure a secure accommodation cell identified as having a faulty intercom must not be used for prisoner accommodation, with cells recorded as unserviceable on IOMS until fault rectified
3. QCS implement uniform state-wide practice ensuring inaudible or garbled intercom calls from prisoners are dealt with in responsive and timely manner
4. TCC General Manager conduct risk analysis program and develop contingency plans setting out staff responsibilities for emergency situations including deaths in custody
5. TCC develop and implement annual training and exercise program concerning responses to credible contingency situations
6. Relevant staff receive refresher training in all aspects of Master Control duties with certification signed off by senior officer and recorded on file
7. CSO assigned immediately to assist responding clinical staff in medical emergencies at correctional centres
8. Compliance with scene preservation requirements must be ensured for all deaths in custody regardless of presumed cause
9. Queensland Police Service Corrective Services Investigation Unit review existing policies for crime scene and evidence preservation at all correctional centres and provide training to CSOs
10. State-wide review and direction to correctional facilities regarding contingency planning for range of scenarios that could impact safety and good order