Coroner's Court of Western Australia

Inquest into the Death of Cally GRAHAM

Delivered on: 31 January 2023

Delivered at: Perth

Finding of: State Coroner Fogliani

Recommendation: I recommend that the Department of Justice give consideration to the development, adoption and promulgation of a post-incident care policy for prisoners involved in or affected by critical incidents.

Orders/Rules: N/A

Suppression Order: N/A

Summary: Cally Graham (Cally) was arrested and imprisoned in February 2017 for the non-payment of her fines in accordance with an administrative process that had applied under the previous provisions of the Fines, Penalties and Infringement Notices Enforcement Act 1994. It was calculated that she needed to spend 6 days in custody to “cut out” her fines. The legislation was amended in 2020 to ensure that for future cases, only a Magistrate can order imprisonment under such circumstances, as a measure of last resort.

An inquest was mandated into Cally’s death because immediately before death, she was in the care of the CEO of the Department of Justice - Corrective Services. Cally would have been discharged to freedom on 24 February 2017. Instead, less that 12 hours after her admission to Melaleuca Prison on 20 February 2017, Cally suffered a cardiac arrest and was conveyed to Fiona Stanley Hospital, where she did not regain consciousness. She died on 26 February 2017. She was 31 years old.

Cally had taken some methylamphetamine before she was taken into custody. The State Coroner found that the cause of Cally’s death was hypoxic ischaemic encephalopathy, bronchopneumonia and myocardial ischaemia complicating a cardiorespiratory arrest in association with probable Takotsubo cardiomyopathy and methylamphetamine effect. The State Coroner was satisfied that the methylamphetamine contributed to Cally’s death, most likely by precipitating a tachyarrhythmia that gave rise to the cascade of events leading to her death. The State Coroner found that Cally’s death was by way of Accident.

At the time of Cally’s admission, Melaleuca Prison had only recently been opened. Some practices and procedures were still being developed and some staffing issues were still being worked out. When the night nurse and custodial staff arrived to resuscitate Cally, there was no functioning oxygen tank to attach to the Oxy Viva resuscitation kit brought by the nurse (as the tank was found to be empty). Cally was ventilated by means of rescue breaths from her cellmate. 

The State Coroner found that while Cally’s prospects of survival, after her cardiac arrest, were very slim, they were not wholly absent. Were it not for the cellmate’s rescue breaths, the State Coroner would have concluded that the CPR provided by Melaleuca Prison was not of an appropriate standard. However, in light of the cellmate’s rescue breaths (together with other first aid that included compressions) the State Coroner was satisfied that Cally was afforded an appropriate opportunity for lifesaving CPR.

In the circumstances the State Coroner found that Melaleuca Prison’s standards of care fell below what should ordinarily be expected in delivering CPR for Cally, by reason of not having a functioning oxygen tank when the staff entered Cally’s cell, as a consequence of which it took another 8 minutes to make one available.

The State Coroner referred to improvements since Cally’s death, including in the area of the availability of, and the checking of, resuscitation equipment. 

Catch Words: Mandatory Inquest: Death in Custody: Accident : Resuscitation of prisoners : Melaleuca Prison.

Last updated: 9-Feb-2023

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