Inquest into the Death of Dannielle Stacey LOWE

41y · Female·complications of intracerebral haemorrhage due to ruptured aneurysm

Dannielle Stacey Lowe, a 41-year-old Aboriginal woman, died in custody at Wandoo Rehabilitation Prison from complications of intracerebral haemorrhage due to a ruptured cerebral aneurysm. Critical missed opportunities in clinical assessment occurred across four consultations. On 6 December 2022, Ms Lowe presented with sudden-onset severe headache and three hours of vomiting—a presentation consistent with possible subarachnoid haemorrhage that warranted emergency department evaluation. This presentation was inadequately assessed by the medical officer who did not review prior records. On 11 December, a nurse failed to address headaches listed on the appointment request form, citing a misunderstood 'therapeutic program' philosophy. On 21 December morning, another sudden-onset headache after bending—pathognomonic for raised intracranial pressure—was managed by nursing staff alone without medical review. That afternoon, Ms Lowe suffered catastrophic intracerebral haemorrhage. Early recognition and imaging on 6 December could have identified the aneurysm for preventive treatment. Systemic failures included inadequate medication logging preventing recognition of pattern of analgesic requests, and a nurse's cognitive bias from prior benign presentations.