Coroner's Finding: PARKER Laura

Contributing factors

• epileptic seizure leading to cardiac arrest
• delayed entry to cell after seizure detected
• failure to notify medical staff immediately of Code Black
• delay in calling ambulance service
• erratic non-compliance with anticonvulsant medication (missed doses prior to collapse)
• prolonged sleep deprivation (72 hours without sleep)
• prolonged solitary confinement in degraded cell environment
• failure to expedite court-ordered psychiatric assessment
• application of inappropriate community mental health management plan to custodial setting
• inadequate seizure risk assessment despite recent seizure history
• lack of awareness by correctional staff of prisoner's epilepsy diagnosis
• lack of information transfer from police custody regarding recent seizures
• hesitation of correctional officers to enter cell without protective equipment
• medical staff not equipped with radios to hear Code Black broadcasts

Coroner's recommendations

1. Establish a database containing medical histories of all prisoners held in police custody and correctional institutions, accessible to authorized personnel of SAPOL, DCS, and PHS
2. Develop protocols for sharing of information between DCS and PHS regarding medical histories and clinical presentations of individual prisoners
3. Introduce legislation to overcome confidentiality considerations for implementation of database and information-sharing recommendations
4. Prison Health Service to develop a protocol for clinical management of prisoners with epilepsy
5. Conduct medical review upon induction of each prisoner with diagnosed epilepsy, including assessment of anticonvulsant medication efficacy, recent seizure history, and seizure risk assessment considering sleep disturbance, medication non-compliance, and recent seizure history
6. Ensure DCS officers are made aware of individual prisoner's epilepsy diagnosis and associated risk assessments
7. Provide training to DCS officers regarding epilepsy, its fatal consequences, and risk factors for seizure
8. Amend DCS Standard Operating Procedures to include specific direction that any episode of unconsciousness or unresponsiveness is a medical emergency requiring immediate intervention without delay
9. Remind DCS officers verbally and in writing that Code Black identification requires immediate notification of medical staff and assessment of need to call emergency services
10. Advise DCS officers verbally and in writing not to resist or question clinical decisions by Prison Health Service staff and to facilitate such decisions without delay
11. Equip Prison Health Service medical staff with DCS radios to enable them to be advised of Code Black when called
12. Amend section 36 of Correctional Services Act to prohibit delegation of section 36 powers to officers below position of General Manager
13. Amend section 36 of Correctional Services Act to require the Minister and Chief Executive Officer to be regularly informed of current circumstances of prisoners subject to separation orders
14. Amend DCS Standard Operating Procedures to require General Manager to regularly review circumstances of prisoners subject to section 36 of Correctional Services Act