Inquest into the Death of Amy TINKER
Deceased
Amy TINKER
Demographics
33y, female
Date of death
2010-09-15
Finding date
2014-01-31
Cause of death
multiple organ failure complicating sepsis in a woman with cirrhosis of the liver
AI-generated summary
Amy Tinker, a 33-year-old Aboriginal woman with unrecognised cirrhosis from chronic alcohol abuse, died from sepsis-related multi-organ failure while imprisoned. She had been admitted to Royal Perth Hospital in 2004 with decompensated liver failure but this critical history was not communicated to prison medical staff during her 2010 incarceration. A psychiatrist's July 2010 recommendation for liver assessment was received but resulted in delayed blood tests that were never completed before her transfer between prisons. On 13 September, she presented with non-specific symptoms (headache, dizziness) and was assessed for dehydration only. She deteriorated rapidly with sepsis and died two days later. The coroner found the Department had implemented appropriate systemic improvements post-death (pathology monitoring protocols, health screening enhancements, transfer fitness assessments) but concluded these changes could not have prevented her acute septic event, though earlier liver disease identification might have enabled preventive interventions.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- chronic alcohol abuse
- malnutrition
- unrecognised cirrhosis
- failure to communicate prior medical history of liver failure to prison medical staff
- delay in completing liver function testing
- non-specific presentation of sepsis in withdrawn patient
- Stenotrophomonas maltophilia infection
Coroner's recommendations
- Amalgamate requirements for prison musters into one standing order to ensure prisoners are required to stand beside their beds during muster checks to enable earlier detection of unwell prisoners
- Develop a guide or checklist for nursing staff regarding procedures for pathology tests for prisoners, including monitoring systems to ensure results are received and acted upon
- Improve or replace the EcHO electronic medical record system to flag pending medical examinations and appointments; implement weekly safety meetings to identify missing test results and establish an IT administrator role to monitor test follow-up
- Extend the health assessment and fitness-to-travel policy directive to apply to internal prison transfers and appointments, not only external escorts, to prevent disruption of ongoing medical care during prisoner transfers
- Implement pro forma screening tools for liver disease in prison health assessments based on patient demographics, risk factors such as alcohol use, and medication history
- Consider the use of non-invasive tissue elastography (FibroScan) technology for cirrhosis screening in prison health services or ensure reliable access to this testing through external providers
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