Coroner's Finding: GIBSON Ian Keith

Contributing factors

• sudden ventricular arrhythmia secondary to severe cardiomyopathy with scarring
• inability to detect cardiac deterioration due to distance observation
• inconsistent and inadequately documented observation checks
• failure of observers to approach cell at required proximity
• uncertainty regarding who conducted specific observation checks
• officers not aware of or failing to apply General Order requirements for regular breathing pattern assessment
• use of remote observation from cell guard office instead of close proximity checks
• inadequate understanding of difference between sleep and unconsciousness in clinical context

Coroner's recommendations

1. Remind staff working within SAPOL cell complexes that an apparently sleeping prisoner may be in a state of unconsciousness and that wellness cannot simply be assumed by the fact that the prisoner appears to be asleep.
2. Checks on High Need prisoners should be conducted by officers who are in close proximity to the prisoner, especially in relation to prisoners whose health may be compromised and especially when they are apparently sleeping. Checks should not be made remotely from another room across a corridor or purely by way of CCTV. The checks should also be made from a location at which CCTV coverage will demonstrate that the checks have been made by the officer conducting them.
3. Cell guards and other SAPOL personnel operating in cell complexes should demonstrate knowledge of and a proficiency in the requirements set out in SAPOL General Order Custody Management.
4. SAPOL personnel working in cell complexes should be instructed and/or reminded that the officer who conducts an observation check on a prisoner must be the officer under whose name the record of that check is made, and the details of what is actually observed must be entered into the check record. Simple records such as 'breathing aac' should not be regarded as appropriate and sufficient.