Inquest into the Death of Peter Johnnie YOUNG

Contributing factors

• Advanced alcoholic cirrhosis
• Hepatitis C infection acquired in prison
• Multi-organ failure including hepatic and renal failure
• Aspiration pneumonia
• Hepatic encephalopathy
• Hepatorenal syndrome
• Rapidly progressive liver decompensation
• Limited preventive monitoring prior to acute deterioration
• Appointment scheduling failures in January-March 2019
• Resource constraints limiting routine clinical reviews

Coroner's recommendations

1. Department must actively notify all family members as quickly as possible when a prisoner's health suddenly deteriorates, to allow time for family to make arrangements to visit or seek legal advice about bail applications
2. For remand prisoners, the opportunity for bail applications must be presented to the prisoner and their legal representatives when health status changes
3. Improve recording of next-of-kin notifications (whether successful or otherwise) - a Deputy Commissioner's Broadcast was issued requiring this
4. Establish coordinated processes for identifying terminally ill remand prisoners and alerting their family, guardian, and lawyer about bail application possibilities - a position has been reinstated with this specific responsibility
5. Improve waitlist management and safety netting for cancelled or rescheduled appointments in prison health services through better business rules and regular multidisciplinary meetings
6. Increase health staffing in prisons to manage prisoners with chronic health issues, with target of GP review at least every three months and nurse care plan visits for complex conditions
7. Ensure new health facilities at Casuarina are appropriately staffed for preventative health care management of prisoners with chronic conditions
8. Provide adequate administrative support to the Director of Prison Health Services through a professional assistant and Deputy Director role
9. Develop comprehensive multisystem management care plans for cirrhosis patients, with annual review in conjunction with hepatologists
10. Provide education to prison health staff regarding documentation, results management, and cirrhosis care protocols