Inquest into the Death of David John HATCHER

Contributing factors

• Active pulmonary tuberculosis diagnosed during first admission
• Severe pre-existing chronic obstructive pulmonary disease (emphysema)
• Significant malnutrition and deconditioning
• Patient refusal of nutritional intervention and rehabilitation
• Low mood and lack of motivation despite psychiatric intervention
• Multi-organ sepsis on second admission
• Acute decline in kidney function
• Heart damage (elevated troponin)
• TB-immune reconstitution inflammatory syndrome
• Progressive lung failure with secondary cardiac involvement
• Failure to update terminally ill status on electronic systems
• Application of restraints contrary to policy on two occasions
• No TB screening at prison intake despite respiratory risk factors

Coroner's recommendations

1. Implement automatic population of terminally ill status from Terminally Ill Register to TOMS Medical Status module and Offender Movement Information (OMI) module to prompt consideration of External Movement Risk Assessment (EMRA) requirements.
2. Target date of 30 June 2026 for TOMS system upgrades to ensure Terminally Ill field is simultaneously updated when a prisoner transitions through terminally ill stages.
3. Create interface between Terminally Ill list and OMI on TOMS to ensure accurate recording when prisoners are transferred.
4. Continue focus on implementing system improvements to assist health services and custodial staff to comply with Commissioner's Operating Policies and Procedures relating to restraints and ensure comfort and dignity of terminally ill prisoners.
5. Consider whether the Department's Operations Centre (available 24/7) would be better suited to conducting oversight reviews of restraint application compared to the Operational Compliance Team (weekday only).
6. Continue TB screening as part of routine blood tests upon prison admission (newly implemented practice).
7. Ensure clarity in TOMS Medical Status module regarding responsibility for recording prisoner terminally ill status (health services responsibility).
8. Disseminate guidance to medical officers regarding updating TOMS Medical Status module to reflect terminally ill status (Dr G. to produce short guide and PM30 Policy and Procedure to be updated).