Inquest into the Death of Arulselvam VELMURUGU

Contributing factors

• lack of appropriate triage system at processing centre
• delay in transfer from jetty to induction centre (approximately 1 hour from identification)
• failure to immediately identify deceased upon arrival at processing centre
• disorganised medical equipment management (non-functional oximeter)
• unavailable defibrillator at point of collapse
• possible miscommunication regarding salbutamol dosing between physician and nurse
• patient disconnected from oxygen during transfer to toilet facilities
• lack of clinical guidelines available to IHMS staff
• no formal training on asthma management provided to nursing staff
• rapid unexplained deterioration despite appropriate initial treatment

Coroner's recommendations

1. Implement triage system with coloured cards and direct handover between nurses (subsequently implemented by IHMS)
2. Provide emergency medical supplies (Thomas Packs) at jetty and induction areas (subsequently implemented)
3. Ensure medical equipment is operational, regularly checked, and staff are aware of location and usage
4. Make clinical guidelines available to health care providers (Therapeutic Guidelines subsequently provided to IHMS clinicians)
5. Provide training and e-learning modules to clinicians on relevant medical topics such as asthma (subsequently implemented)
6. Consider availability of ambulance at jetty when large numbers of detainees arrive
7. Review coordination between jetty screening and processing centre to ensure timely hospital transfer for unwell detainees