Inquest into the Death of Ashley Adrian LANE

Contributing factors

• poorly controlled asthma not recognized as terminal illness requiring different management
• failure to obtain and review recent hospital admission records at reception
• incorrect prisoner medical summary in system despite later receipt of community records
• nebuliser issued for overnight cell use without physician approval or parameters
• lack of 24-hour nursing support at regional prison
• failure to recognise severity of March 2019 near-fatal exacerbation as indicator of need for specialist review
• failure to call ambulance despite prisoner stating 'can't breathe properly'
• failure to call Code Red medical emergency
• absence of clear medical alert system for high-risk prisoners
• absence of asthma action plan despite literacy limitations
• nebuliser part placed in red box delivery system rather than hand-delivered by nursing staff
• red box system not designed for medical equipment delivery
• no respiratory physician referral despite repeated severe exacerbations
• smoking cessation not effectively achieved despite advice
• inadequate information in broadcast email about nebuliser use and medical emergency response

Coroner's recommendations

1. DOJ should conduct a review of nursing support at EGRP to determine whether statutory responsibilities are being properly discharged, considering additional nursing staff during day shifts for health education and health audits, and considering nursing cover between 6.30pm and 6.30am.
2. DOJ should employ a staff development nurse responsible for enhancing nursing staff skills, health education, management of chronic medical conditions, and assisting with scenario-based training for prison officers responding to medical emergencies.
3. Maintain a list of prisoners with serious medical conditions in Master Control Room and on relevant units so officers receiving cell calls from these prisoners are aware urgent ambulance attendance may be required.
4. DOJ should issue a bulletin reminding staff that checking for a pulse before starting CPR is obsolete and CPR should be commenced whenever a patient is not breathing, not breathing properly, not responding and/or not moving.
5. DOJ should issue a bulletin reminding all prison officers that regardless of rank, all officers have independent discretion to call Code Red medical emergency and/or call for ambulance, with no disciplinary consequences for good faith calls.
6. Local Order 1 should be amended to make clear the Red Box system is only for delivery of oral medication and under no circumstances is to be used for medical equipment or components thereof.
7. EGRP should conduct bi-monthly scenario-based training exercises to enhance skills in responding to medical emergencies, including obtaining information during emergency cell calls, de-escalation, cell breach and resuscitation procedures, using past medical emergencies as training examples.
8. DOJ should amend the At Risk Management System - Reception and Intake Assessment form to include the question 'In the past 12-months have you attended, or been admitted to a hospital', with nurses also asking this during initial health screening, and promptly obtaining hospital records when answered affirmatively.