Inquest into the Death of Ms DHU

Contributing factors

• Rib fracture from domestic violence sustained April 2014 that did not heal
• Intravenous amphetamine use introducing staphylococcus aureus bacteria
• Failure to diagnose infection at hospital presentations on 2-3 August 2014
• Premature diagnostic closure by emergency doctors attributing symptoms to behaviour issues and drug withdrawal
• Failure to take temperature at any point during emergency department visits
• Failure to perform chest X-ray despite second presentation with chest pain
• Failure to appropriately assess tachycardia (pulse 113-126 bpm)
• Police belief that she was feigning symptoms
• Delayed ambulance transfer on 4 August 2014
• Police detention over weekend in police lock-up rather than transfer to prison
• Compromised immune system from drug use
• Social determinants of ill health and Aboriginal disadvantage

Coroner's recommendations

1. Formalisation of dedicated lock-up keeper roles at every police station or minimum of two officers rostered for custodial care duties
2. Mandatory training course on roles and responsibilities of lock-up keeper/supervisor with face-to-face component before assignment
3. Mandatory initial and ongoing cultural competency training for police officers to understand Aboriginal health concerns with Aboriginal involvement in delivery
4. Cultural competency training tailored to local community issues for officers transferred to locations with significant Aboriginal populations
5. Parliament consider legislative change to allow medical clinicians to provide police with sufficient medical information to manage detainee care whilst in custody
6. Amendment to Fines, Penalties and Infringement Notices Enforcement Act section 53 to prohibit warrant of commitment authorising imprisonment or require Magistrates Court hearing and determination
7. High priority for Parliament to consider Justice Ministers' Working Group pending reforms on alternatives to incarceration including out-of-court options for low-level offenders
8. Fine defaulters incarcerated pursuant to Warrant of Commitment should be transported to nearest prison within 4-8 hours of arrest where transport time does not exceed detention period
9. Policy requiring police to contact Aboriginal Visitors Scheme after deciding to detain Aboriginal offender in lock-up
10. State Government consideration of establishing Custody Notification Service based on New South Wales model operating 24/7 alongside Aboriginal Visitors Scheme
11. Lock-up procedure manual amendment to reference greater monitoring for detainees with severe symptoms, recognition that new symptoms may signify deterioration, acknowledgment that drug/alcohol use can mimic serious illness, and requirement for immediate ambulance conveyance of unconscious detainees