Coronial
WAother

Inquest into the Death of Judy Sonia BOLTON

Deceased

Judy Sonia BOLTON

Demographics

44y, female

Date of death

2016-12-10

Finding date

2019-08-20

Cause of death

acute myocardial infarction due to coronary thrombosis

AI-generated summary

A 44-year-old Aboriginal woman died from acute myocardial infarction (heart attack) due to coronary thrombosis while in custody at Bandyup Women's Prison in Western Australia. She had multiple cardiovascular risk factors: Aboriginal status, obesity, smoking, hypertension, and dyslipidemia (detected late). Blood pressure monitoring was inadequate, with rapid de-escalation once readings normalised. Her hyperlipidaemia was not detected until November 2016 due to missed appointments and failed testing attempts. Nurse Owen's initial assessment was reasonable given the deceased presented with subtle symptoms typical of female presentation (no cold sweat, pallor, or severe distress). She walked to the medical centre (with hindsight, a wheelchair would have been preferable). At the medical centre, an ECG was performed and abnormality detected; ambulance was called appropriately. The deceased received high-quality care at Royal Perth Hospital but could not be revived. Key lessons: earlier cardiovascular risk recognition and proactive management could have been beneficial; consistent blood pressure monitoring protocols; better prison medical facilities needed; new protocols now in place (Code Red for chest pain, emergency chest pain pathways, improved EcHO system).

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

cardiologyemergency medicinecorrectional health

Error types

diagnosticsystemdelay

Drugs involved

metoprololamiodaronemidazolamsalicylic acidquetiapineheparinglyceryl trinitrateamphetaminecannabis

Clinical conditions

acute myocardial infarctionst-elevation myocardial infarction (stemi)coronary artery diseasecoronary atherosclerosishypertensiondyslipidaemiaobesitycardiac arrest

Procedures

electrocardiogramcardiac catheterisationthrombus aspirationstent insertioncannula insertioncardiopulmonary resuscitationdefibrillation

Contributing factors

  • Aboriginal status (cardiovascular risk factor)
  • obesity
  • smoking
  • hypertension with inadequate monitoring
  • dyslipidaemia detected late (November 2016)
  • missed blood test appointments
  • failed phlebotomy attempts
  • non-attendance at medical appointments
  • non-compliance with blood pressure medication in community
  • adverse childhood events and trauma history
  • staff shortages in prison medical centre
  • high prison muster (overcrowding)
  • prison medical centre not fit for purpose

Coroner's recommendations

  1. Introduce 'Code Red Medical Emergency' protocol for all chest pain presentations in all Western Australian prisons (now implemented since July 2018)
  2. Chief Executive Officer of Department of Corrective Services to take urgent action to remediate the medical centre's shortcomings and upgrade facilities to be fit for purpose
  3. Regular and proactive monitoring of blood pressure in prisoners with hypertension, rather than rapid de-escalation to 'as required' basis
  4. Implement cardiac care plans embedded into EcHO system for high-risk cardiovascular patients
  5. Improve education and consistency of health promotion regarding smoking cessation, weight management, diet and exercise
  6. Consider authorising prison nurses to administer GTN without prior medical officer approval
  7. Each cardiac catheter laboratory should be equipped with its own LUCAS (automated CPR) machine to avoid delays
  8. Review and modernise the ECG transmission process from ambulances to cardiac catheter laboratories to reduce multi-step manual processes
  9. Ensure consistent documentation of health literacy services in EcHO using service codes
  10. Align annual health assessment templates with Medicare items for Aboriginal and Torres Strait Islander assessment
  11. Address staff shortages in prison medical centres through adequate staffing and backfill policies
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