Coroner's Finding: PARKER Laura

40y · Female·hypoxic encephalopathy and epilepsy with diffuse fibrillary astrocytoma within the right occipital lobe

Laura Parker, a 40-year-old woman with a long history of epilepsy, borderline personality disorder, and recent seizures, died at the Royal Adelaide Hospital on 16 March 2008 from hypoxic encephalopathy caused by cardiac arrest following an epileptic seizure while in remand custody at Adelaide Women's Prison. Critical clinical lessons include: (1) failure to assess and manage seizure risk despite clear indicators (recent seizures, medication non-compliance, 72-hour sleep deprivation); (2) inappropriate application of a community mental health management plan to a custodial setting, which recommended avoiding detention despite manifestations of acute psychiatric illness; (3) delayed response to medical emergency—over 10 minutes elapsed before cell entry after seizure detection; (4) failure to notify medical staff immediately of the Code Black; (5) inappropriate focus on protective equipment delay rather than urgent life-saving intervention. The court-ordered psychiatric assessment was scheduled for days later rather than expedited. Earlier professional medical evaluation, timely seizure risk assessment, appropriate Mental Health Act detention, and immediate response protocols could potentially have prevented this death.