Mitchell, Vanelee Curtis

Contributing factors

• Missed anticonvulsant medications on afternoon of 9 April 2020
• Subtherapeutic anticonvulsant blood levels (Valproate 6.2 mg/L, Levetiracetam 0.68 mg/L, both below therapeutic range)
• History of poorly controlled epilepsy with frequent seizures when medications missed
• Possible valproate-induced hypoglycaemia
• Low security custodial setting with voluntary medication compliance model

Coroner's recommendations

1. Encourage continuation of THHS Health Equity Strategy 2022-2025 to reduce inequalities between Indigenous and non-Indigenous health outcomes
2. Implement Indigenous Liaison Officers (ILO) or Indigenous Health Workers (IHW) within Townsville Prison Health Service
3. Improve information sharing protocols between Queensland Corrective Services and Queensland Health
4. Embed culturally appropriate support and engagement strategies in health service delivery to prisoners
5. Expand reception triage program to include further exploration of illness, disease, and injuries for inmates from remote communities
6. Review '3-day rule' for medication non-compliance intervention with aim to introduce dose-aid packaging system to shorten timeframe from 3 days to 1-2 days