Inquest into the Death of Michael James HARDIE

Contributing factors

• methylamphetamine use increasing blood pressure and negating blood pressure medication benefits
• persistent smoking despite medical advice to abstain
• failure to communicate security information about suspected drug trafficking between facilities
• absence of targeted drug testing and cell searches at receiving facility
• lack of leadership during resuscitation efforts
• disengagement from specialist medical advice

Coroner's recommendations

1. Create a 'Management Transfer' alert within the Total Offender Management System (TOMS) to identify prisoners transferred between prisons for security and safety reasons, including suspected involvement in drug trafficking
2. Require security managers at transferring facilities to contact security managers at receiving facilities to communicate the reason for prisoner transfer and discuss surveillance measures, documented by follow-up email
3. Develop and finalise policies and procedures for end-of-life planning including advance health directives, Do Not Resuscitate decisions, and prison staff response protocols; consider appropriateness of DNR alert in TOMS
4. Conduct regular scenario-based training exercises relating to medical emergencies at all prisons (bi-monthly suggested)
5. Issue bulletin reminding staff that pulse-checking before CPR is obsolete and CPR should be commenced when patient is not breathing, not responding and/or not moving