Inquest into the Death of Amy TINKER

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• non-specific presentation of sepsis in withdrawn patient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

1. 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
2. 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
3. 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
4. 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
5. 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
6. 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