Coroner's Finding: KEN Kenneth Ngalatji

Contributing factors

• failure to place deceased in infirmary despite recommendation from Port Augusta Prison
• missed psychiatric appointment due to inflexible lockdown procedures and failure to prioritise urgent case
• inadequate clinical assessment of chest pain despite borderline ECG and cardiac risk factors
• failure to compare current ECG with previous baseline ECG from week prior
• lack of cardiac risk stratification despite known hypertension, smoking, elevated cholesterol
• failure to perform point-of-care Troponin testing
• deceased placed alone in cell despite HRAT status requiring double occupancy
• failure to escalate communication regarding accommodation recommendations from Port Augusta
• inadequate mental health assessment of hallucinations and paranoid delusions
• cultural bias in psychiatric assessment leading to dismissal of psychiatric symptoms as culturally-based
• failure to ensure psychiatric appointment occurred as scheduled
• inadequate supervision and monitoring of HRAT requirements at operational level

Coroner's recommendations

1. Department for Correctional Services and South Australian Prison Health Service should revise procedures for prisoner transfers between institutions, including formal handovers between HRAT teams, DCS management, and SAPHS staff; handovers should identify accommodation recommendations and reasons for transfer including need for medical/psychiatric evaluation
2. Formal handovers should occur between Aboriginal Liaison Officers at transferring and receiving institutions
3. DCS Prisoner Movement orders should detail reasons for transfer and recommended accommodation arrangements
4. Communication should occur between institutions at time of prisoner departure with accurate arrival time expectations
5. Department for Correctional Services should implement electronic monitors displaying live lists of HRAT prisoners in unit staff offices
6. DCS staff should endorse documents acknowledging HRAT prisoners are not left alone during lockdowns
7. Transfers of HRAT prisoners between units should never rely solely on word-of-mouth communication
8. All HRAT prisoner transfers should involve formal enquiry as to HRAT status
9. Induction checklists should examine JIS casenotes and prominently display HRAT documentation
10. DCS units should maintain continuity of supervisory personnel who establish identities of all HRAT prisoners
11. DCS unit supervisors should personally oversee HRAT prisoner transfers and endorse NOCs
12. Medical practitioners should conduct thorough examination of prisoners with chest pain; if impracticable, prisoner should remain in Health Centre until examination completed
13. Prisoners with chest pain should be questioned regarding cardiac risk factors and previous ECG traces should be compared with current traces
14. South Australian Prison Health Service should compile chest pain protocol similar to public hospital emergency departments
15. Point-of-care Troponin testing should be available in all SAPHS facilities
16. Lockdown schedules should never influence clinical management of chest pain; prisoners should not be returned to units until acute cardiac illness excluded
17. Aboriginal prisoners presenting with hallucinations or delusions should be assumed psychiatrically-based until demonstrated otherwise; cultural factors should not delay psychiatric evaluation
18. All SAPHS facilities should employ or have ready access to qualified Mental Health nurses
19. Triage process should be introduced for psychiatric evaluations with urgent cases accorded priority; appointments should never be postponed due to lockdown schedules
20. HRAT should oversee and manage carrying out of psychiatric appointments to ensure they occur
21. Psychiatric appointments by CCTV should be conducted to avoid prisoner transfers
22. SAPHS personnel opinions should prevail in disputes with DCS regarding prisoner transfer to health facilities
23. Establishment of prison 'In-reach team' operated by Statewide Forensic Mental Health Services with nursing staff, video link assessments, family consultation, and multi-disciplinary approach
24. Consider amendment to Mental Health Act 2009 regarding inpatient treatment orders on persons in DCS custody to address least restrictive environment principles and recognition of prisoner liberty restrictions
25. Hanging points should be eliminated from all cells in correctional institutions