Wright, Kenneth Douglas

Contributing factors

• failure to provide supplemental oxygen despite oxygen saturation of 77%
• failure to maintain continuous monitoring after documented deterioration
• inadequate escalation of clinical concerns to ambulance services
• no clear priority conveyed when requesting ambulance transfer
• absence of acute resuscitation plan despite guardianship order
• incomplete communication between nursing and correctional staff regarding ambulance requests
• lack of formal policies and procedures for Advanced Care Unit nursing practice
• inadequate orientation and supervision of new graduate nurse

Coroner's recommendations

1. Serco and Queensland Corrective Services should conduct a review of the process for calling ambulance attendance at SQCC and the priority given to those requests. Consideration should be given to authorising clinical staff to directly request urgent ambulance assistance.
2. Implementation of deterioration detection systems (Q-ADDS tool) for all prisoners admitted to Advanced Care Unit
3. Development of more defined policies, procedures and protocols specific to Advanced Care Unit nursing practice
4. Improved communication channels between nursing and correctional staff regarding ambulance requests
5. Consideration of whether clinical staff should have direct access to call QAS rather than requesting through correctional staff