Finding into death of Damien Nobile
Deceased
Damien Nobile
Demographics
37y, male
Date of death
2016-01-04
Finding date
2018-03-09
Cause of death
Acute epiglottitis
AI-generated summary
A 37-year-old male prisoner presented with a sore throat and was assessed by a doctor who found only minor inflammation and no signs of bacterial infection, treating conservatively with analgesia. Eight hours later, after reporting difficulty breathing and throat swelling, a nurse assessed him through the cell trap door without taking vital signs, finding him apparently stable and reassuring him with follow-up planned. Within an hour, the patient deteriorated significantly with respiratory distress. Despite eventual ambulance transport and treatment, he died from acute epiglottitis. Key clinical lessons: vital signs should always be documented at initial assessment; any deterioration requires thorough re-evaluation with proper vital sign monitoring; epiglottitis can progress rapidly and requires high clinical suspicion in a patient with sore throat and stridor/breathing difficulty; custodial settings should not compromise medical care standards.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Coronary artery atherosclerosis
- Failure to document vital signs at initial assessment
- Inadequate clinical assessment at second attendance through cell trap door
- Delay in recognition of severity of condition
- Initial misdiagnosis as asthma rather than epiglottitis
Coroner's recommendations
- Hopkins Correctional Centre Medical Clinic introduced a minor response bag for nurses to carry when attending to assess prisoners away from the clinic, including equipment for clinical observations and vital signs
- Correct Care Health Service Managers reiterated to nursing staff the importance of requesting corrections staff to open cells to undertake proper physical review of prisoners
- Correct Care developed a 'Medical & Nursing Response Record' form to promote contemporaneous documentation of event times, vital signs and other relevant information
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