Inquest into the Death of Hassan BECHARA

Contributing factors

• failure to identify need for specialist cardiac care on prison admission
• delayed review of community medical information from New South Wales doctors
• four-month delay in commencing cholesterol-lowering medication (atorvastatin)
• prisoner not placed on Terminally Ill list despite meeting criteria
• staff shortages and inadequate prison medical officer workforce leading to administrative backlogs
• time pressures preventing thorough review of voluminous incoming medical records
• patient non-compliance with investigations and recommended procedures including previous refusal of ICD and angiogram

Coroner's recommendations

1. The Department of Justice should make every effort to urgently recruit more prison medical officers to improve health service delivery within the prison system
2. Medical assessment templates on admission should include specific questions about involvement of community specialists in prisoner's medical care
3. Release of information forms should include specific questions directed to specialists to ensure information is received directly from those specialists
4. Improvements should continue to the release of information process including MyHealthRecord links and requesting medical summaries to reduce volume of material received and speed uploading into electronic health records
5. Continue education provision to Prison Medical Officers on prevention, recognition, investigation and management of cardiac failure, including advice on when to refer prisoners to specialist care