Coronial
QLDother

Harmer, Jay Maree

Deceased

Jay Maree Harmer

Demographics

38y, female

Date of death

2016-07-02

Finding date

2018-08-10

Cause of death

Complications of decompensated liver failure due to cirrhosis secondary to Hepatitis C infection with non-alcoholic steatohepatitis

AI-generated summary

Jay Maree Harmer, 38, died in custody from decompensated liver failure secondary to Hepatitis C cirrhosis. She had advanced hepatic encephalopathy, opioid dependence, and obesity. Despite specialist recommendations to remain hospitalized for palliative care, she self-discharged against medical advice on 28 June 2016 and returned to the prison. She died four days later, likely from respiratory arrest due to prone positioning combined with altered consciousness from hepatic encephalopathy, opioid use, and multiple medications. Clinical lessons include: earlier palliative care planning should have been initiated in 2015; timely discussion of poor prognosis was delayed; exceptional circumstances parole application was made too late; prisoner carers lack adequate training in recognizing airway compromise risks in high-risk positions; and 24-hour nursing care was unavailable at the prison facility. Better coordination between correctional services, health providers, and the parole board could have enabled timely release to palliative care.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

gastroenterologypalliative carecorrectional healthpsychiatry

Error types

communicationdelaysystem

Drugs involved

buprenorphinetapentadolsertralinepregabalinquetiapinelactulosemacrogolrifaximin

Clinical conditions

cirrhosishepatitis c infectionhepatic encephalopathyportal hypertensionoesophageal varicesnon-alcoholic steatohepatitisopioid dependenceasthmairon deficiencybipolar affective disorderpost-traumatic stress disorder

Contributing factors

  • advanced hepatic encephalopathy with altered level of consciousness
  • prone sleeping position
  • facial and airway oedema from advanced liver disease
  • obesity and suspected obstructive sleep apnoea
  • respiratory depression from opioid medications (buprenorphine, tapentadol)
  • somnolent effects of prescribed medications (sertraline, pregabalin, quetiapine)
  • return to prison against medical advice
  • lack of 24-hour nursing care at correctional facility
  • inadequate palliative care infrastructure in prison
  • delayed parole application process
  • insufficient training of prisoner carer in airway management and risk recognition

Coroner's recommendations

  1. Queensland Government comprehensively review the model for provision of palliative care to prisoners with view to improving how and where palliative care is delivered, including provision of post-release supported accommodation options for infirm prisoners eligible for exceptional circumstances parole
  2. Queensland Corrective Services develop formal policy on selection, training and management of prisoner carers, including requirement that prisoner carers be trained in basic first aid
  3. Queensland Government ensure Parole Board Queensland has access to medical, psychiatric and psychological reports tendered during sentencing proceedings, facilitated by court orders requiring such reports be provided to QCS
  4. Queensland Corrective Services and Parole Board Queensland prepare guidelines to assist doctors preparing reports for exceptional circumstances parole applications, clarifying relevant considerations and level of expertise required, with consideration given to obtaining advice from Clinical Forensic Medicine Unit
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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