Inquest into the Death of Dannielle Stacey LOWE

Contributing factors

• failure to escalate sudden-onset severe headache with vomiting to emergency department on 6 December 2022
• inadequate initial medical assessment without review of medical records
• failure to address headaches on appointment request form on 11 December 2022
• cognitive bias from prior benign headache presentations affecting assessment of 21 December presentation
• failure to arrange medical review for sudden-onset headache on 21 December 2022
• failure to record after-hours medication dispensing between November 2022 and March 2023, preventing identification of pattern of analgesic requests
• lack of investigation into reasons for ongoing overnight analgesia requests
• misunderstanding of therapeutic community ethos by nursing staff regarding clinical assessment obligations

Coroner's recommendations

1. The Department of Justice should make it mandatory for all prison nurses and doctors to successfully complete Advanced Life Support Course Level 2 (ALS2) or an appropriate alternative course, within six months after their initial employment, and every three years thereafter.
2. The Department of Justice should issue a Commissioner's Bulletin (or similar) reminding all custodial staff of the importance of strict and ongoing compliance with COPP 6.4 - Officers issuing medication.
3. For the avoidance of doubt, the Department of Justice should issue an instruction to all nursing and medical staff providing health services at Wandoo Rehabilitation Prison, that where a prisoner makes a written request to be reviewed by a nurse or doctor, the health professional conducting that review must ensure that all of the issues referred to by the prisoner in their written request form are addressed, whether raised by the prisoner at the review or not.
4. In order to provide culturally safe care to Aboriginal prisoners in Western Australia, the Department of Justice should redouble its efforts to recruit Aboriginal staff at its prisons, including medical officers, nurses, psychologists, social workers, and prisoner support officers. Culturally safe care for Aboriginal prisoners in Western Australia may also be achieved by establishing partnerships with Aboriginal community controlled health organisations and medical services, to provide access to visits from Aboriginal health practitioners, and by developing an Aboriginal Elders visiting program.