Inquest into the Death of Frank ALBERT

Contributing factors

• severe coronary artery disease with myocardial fibrosis predisposing to cardiac arrhythmia
• uncontrolled diabetes type 2 with poor medication adherence
• prisoner's refusal of prescribed diabetes and lipid-lowering medications due to erroneous beliefs about side effects
• illicit use of quetiapine obtained from another prisoner
• absence of Aboriginal Health Worker to provide culturally appropriate health education
• failure to adequately investigate medication security and trafficking at the prison
• inadequate resources and time pressure at medication parades
• poor quality emergency communication to ambulance services

Coroner's recommendations

1. Issue a state-wide bulletin reminding staff that when requesting an ambulance via 000, they should provide the prisoner's name, age, ethnicity (where relevant), nature of emergency, and whether the prisoner is awake and/or breathing
2. Review the 'All calls to 000' table in the West Kimberley Regional Prison Local Emergency Plan to ensure it requires staff to communicate the prisoner's name, age, ethnicity (where relevant), nature of emergency, and whether the prisoner is awake and/or breathing
3. Conduct a review of time and staff resources allocated to medication parades to determine whether resources are sufficient to prevent illicit trafficking of prescription medication, and consider additional measures to detect medication secretion/diversion attempts, particularly for trafficable medications such as quetiapine
4. Redouble efforts to recruit Aboriginal Health Workers (AHW) especially for regional prisons, with a view to examining the feasibility of ensuring all Aboriginal prisoners with chronic medical conditions are reviewed by an AHW on initial admission and thereafter as appropriate, to identify treatment gaps and provide culturally appropriate education about prescription medications and investigative procedures
5. Liaise with appropriate Aboriginal organisations and Aboriginal health workers to develop culturally appropriate dietary options for Aboriginal prisoners with diabetes, and proactively offer these dietary options to those prisoners