Inquest into the Death of Russell Graham PENNY

Contributing factors

• hepatocellular carcinoma with multifocal liver lesions
• decompensated liver failure
• repeated hepatitis C infections with incomplete treatment between prison terms
• respiratory syncytial virus infection and pneumonia
• missed specialist appointment for treatment planning
• administrative oversight in prisoner movement documentation

Coroner's recommendations

1. The Department should review and consider whether current processes on the TOMS database appropriately highlight urgent upcoming medical appointments for prisoners when custodial movements officers are considering prisoner placements
2. A more prominent alert on the TOMS database may assist custodial movements officers, or further training would assist all staff in accessing all relevant information on the TOMS database to inform movement decisions
3. The Department should ensure that circumstances of Russell's transfer and subsequent missed medical appointment serve as a helpful example in training staff to understand the importance of movements decisions being appropriately informed by a person's medical status and pending external appointments
4. The Department should review policies and procedures applicable to prisoners receiving palliative care in external facilities (such as hospitals) to ensure families have clear, straightforward and simple information about the visit approval process, and that visits are approved without delay when safe and appropriate