Coroner's Finding: RIGNEY Vincent Norman

Contributing factors

• Aboriginal ethnicity with associated increased cardiac risk
• smoking history
• lack of 24-hour medical staffing at Port Augusta Prison
• inadequate cardiac screening and risk assessment
• absence of family history documentation despite family history of cardiac disease
• delayed medical evaluation - symptomatic treatment given by non-medical staff rather than urgent medical assessment
• limited access to defibrillation by trained personnel immediately upon collapse

Coroner's recommendations

1. Department for Correctional Services should institute a 24-hour nursing service at Port Augusta Prison and investigate such a service at all other prisons in the State
2. Department for Correctional Services should provide public access defibrillators or automated external defibrillators to any prison that does not have 24-hour nursing facilities
3. Department for Correctional Services and South Australian Prison Health Service should investigate provision of enhanced cardiac screening for prisoners including resting ECG, exercise ECG, diabetes testing, blood pressure checks, and fasting serum lipid assessment, particularly for high-risk prisoners (Aboriginal background, age, smoking history)