Coroner's Court of Western Australia

Inquest into the Death of Ashley Adrian LANE

Inquest into the Death of Ashley Adrian LANE

Delivered on :21 June 2022

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

Given the higher incidence of serious and/or chronic health conditions amongst the prison population, the Department of Justice (DOJ) should conduct a review of the level of nursing support provided at Eastern Goldfields Regional Prison (the Review) to determine whether the statutory responsibilities of the Chief Executive Officer set out in section 7(1) of the Prisons Act 1981 (WA) are being properly discharged.

The Review should consider whether additional nursing staff should be employed at EGRP during the day to enable proactive health education and health audits to be performed in addition to routine nursing duties.  The Review should also consider whether additional nursing staff should be employed to provide cover at EGRP between the hours of 6.30 pm and 6.30 am.

Recommendation No. 2

DOJ should consider employing a staff development nurse who would be responsible for ensuring that the skills of nursing staff employed within the prison system are continually enhanced, especially with respect to health education and the management of prisoners with chronic medical conditions.  The staff development nurse could also assist in the conduct and review of scenario-based training exercises conducted for the benefit of prison officers that relate to responding to medical emergencies.

Recommendation No. 3

A list of prisoners with serious medical conditions should be maintained in the Master Control room at EGRP and on the respective prisoners units, so that officers receiving cell calls from prisoners on that list are aware that the prisoner making the call may require the urgent attendance of an ambulance.

Recommendation No. 4

DOJ should consider issuing a bulletin to all staff reminding them that the previous practice of checking for a pulse before starting cardio pulmonary resuscitation (CPR) is obsolete and that CPR should be commenced whenever a patient is not breathing, not breathing properly, not responding and/or not moving.

Recommendation No. 5

DOJ should consider issuing a bulletin reminding prison officers that regardless of rank, all officers have an independent discretion to call a Code Red medical emergency and/or call for an ambulance to attend at a prison.  Officers of lower rank and/or less experienced officers should be reminded that the approval of a more senior officer is not required and no disciplinary consequences will apply where the ambulance was called and/or the Code Red medical emergency was initiated in good faith.

Recommendation No. 6

Local Order 1 should be amended to make it clear that the Red box system which operates at EGRP is only to be used for the delivery of oral medication and that under no circumstances is the Red Box system to be used to deliver medical equipment and/or parts or components of medical equipment.

Recommendation No. 7

EGRP should consider conducting bi-monthly scenario-based training exercises (i.e.: 6 per year) to enhance the skills of prison officers and nursing staff in responding to medical emergencies within the prison.  Consideration should be given to including training on issues such as how to obtain information from prisoners during emergency cell calls and how to de-escalate situations as well as appropriate cell breach and resuscitation procedures.  This training could include scenarios based on past medical emergencies to highlight effective and ineffective responses by prison officers and/or nursing staff.

Recommendation No. 8

DOJ should consider amending section 6.6 of the At Risk Management System – Reception and Intake Assessment form used by prison officers receiving prisoners into prison, by including the following question: “In the past 12-months have you attended, or been admitted to a hospital”.  DOJ should also consider ensuring that nurses conducting the initial health screen on a prisoner being admitted to a prison ask the same question.

Where a prisoner answers “Yes” to this question (either to a reception officer or to a nurse), the prisoner should be asked for details of the hospital or medical facility, and as soon as is practicable thereafter, DOJ should obtain records relating to those hospital attendances or admissions.

Orders/Rules : N/A

Suppression Order : Yes

On the basis that it would be contrary to the public interest, I make an Order under section 49(1)(b) of the Coroners Act 1996 that there be no reporting or publication of the name of the deceased’s cell mate on 26 April 2019.  The cell mate is to be referred to as “Prisoner D”.

Summary : Mr Ashley Adrian Lane (Mr Lane) was 56-years of age when he died at Kalgoorlie Regional Hospital (KRH) from acute exacerbation of chronic obstructive pulmonary disease (bronchial asthma) 26 April 2019.

At the time of his death Mr Lane was a remand prisoner at Eastern Goldfields Regional Prison (EGRP), having been received there on 14 February 2019.  During a risk assessment conducted during the reception process, Mr Lane advised he did not have any serious health issues.  However, he had a Ventolin puffer in his possession and disclosed that he had asthma and liver issues.  In fact, medical records several days later showed he had chronic obstructive pulmonary disease.

During his incarceration at EGRP, Mr Lane experienced periodic exacerbations of his asthma which were managed with Ventolin and steroidal medication.  On the evening of 8 March 2019, Mr Lane experienced a near fatal exacerbation of his asthma and was taken to KHC.  He was discharged after three days, but it appears that nobody at EGRP realised that this incident demonstrated that his asthma was poorly controlled and that Mr Lane needed to be referred to a respiratory physician for ongoing management.

On 23 April 2019, Mr Lane was permitted to have a Ventolin nebuliser in his cell overnight and he told nursing staff that this had provided him with relief.  The fact that Mr Lane now required Ventolin overnight was a clear indication that his asthma was poorly controlled, but again this was not appreciated by clinical staff at EGRP.  On 25 April 2019, Mr Lane advised a prison nurse that his nebuliser was not working and she identified that an essential component was damaged and sourced a replacement. The replacement part was placed in a box at the front gate and although the nurse expected that the part would be delivered to Mr Lane immediately, this did not occur.

At 1.32 am on 26 April 2019, Mr Lane used the emergency call button in his cell to alert officers to the fact that he was having trouble breathing.  Although the officers eventually provided Mr Lane with the replacement part for his nebuliser, Mr Lane’s condition quickly deteriorated and he collapsed in his cell.  The cell door was unlocked and Mr Lane was taken to a common area where CPR was commenced.  Although Mr Lane was transferred to KHC where resuscitation efforts continued, he could not be revived.

The Coroner concluded that although Mr Lane’s medical treatment was often commensurate with standards in the general community, his medical conditions were not managed in a holistic way and that he should have been placed under the care of a respiratory physician.  The coroner made eight recommendations intended aimed at improving the health and safety of prisoners at EGRP.

Catch Words : Death in Custody : Health Education and Health Audits : Chronic Medical Conditions : Responding to Medical Emergencies : Natural Causes

Last updated: 3-Aug-2022

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