Goldfields prisoner waited two hours for treatment after stroke, inquest hears

A West Australian coroner says senior staff at a regional prison must understand that preserving life is more important than completing paperwork.

Key Points: It took two hours for the prisoner to be taken to hospital after the alarm was raised. Medical experts testified that the delay was “extremely regrettable” but did not contribute to his death.

Deputy coroner Sarah Linton made the observation while delivering her findings on the death of 48-year-old Mr. Anderson, as he is known for cultural reasons, delivered a “catastrophic” stroke at the Eastern Goldfields Regional Prison (EGRP) in 2020.

But Ms Linton stopped short of blaming prison and hospital staff for Mr Anderson’s death.

She found he had no chance of survival, despite being forced to wait more than two hours for emergency medical treatment.

Mr Anderson was serving a six-month sentence for traffic offenses when he collapsed in his cell on 23 December 2020.

He died the next day from an “unsurvivable” intracerebral hemorrhage, or hemorrhagic stroke, which causes bleeding inside the brain from the rupture of a blood vessel.

The inquest heard that Mr. Anderson had been in custody since Nov. 24 and that he was an alcoholic who had several health conditions, including high blood pressure and diabetes.

Mr. Anderson’s cellmate reported he collapsed at 10.20pm on December 23.

“Miss, please get a doctor. Please. He’s blacked out. Hurry up miss, get a nurse,” mr. Anderson’s cellmate “Jason” said on the prison intercom.

When prison officers arrived at the cell nine minutes later, Mr. Anderson was still conscious and talking but had visible weakness on the left side of his face.

Officers followed protocol by contacting the on-call doctor while speaking with Mr. Anderson and his cellmate communicated through an observation hatch.

They did not open the cell door until 22:45 after conducting a risk assessment in accordance with their training.

Mr. At one point, Anderson coughed up a lot of dark, red blood.

St John Ambulance was not contacted until 11.05pm.

The ambulance arrived at the prison at 23:20 and at 23:40 the unit with Mr. Anderson left, but didn’t leave the jail until 12:16 a.m. because paramedics waited more than half an hour for jail officials to fill out transfer papers.

During that time Mr. Anderson was restrained and prison officials collected an escort vehicle.

The coroner said the delay in caring for Mr. Anderson is “worrying” but that he could not be saved.(ABC Goldfields: Robert Koenig-Luck)Two hours from collapse to hospital

The inquest heard that Mr. Anderson arrived at the emergency department of Kalgoorlie Health Campus at 12:25.

He was tested as a category 3 patient – to be seen within 30 minutes – and was diagnosed with a probable stroke after he collapsed at 12.36am.

The inquest was told that Mr. Anderson’s condition continued to deteriorate and a head CT scan performed at 1:40 a.m. showed a very large acute cerebral hemorrhage with surrounding brain edema.

Mr Anderson’s case was discussed with neurosurgeons at Royal Perth Hospital, who advised that he was not suitable for surgical treatment and should be managed palliatively.

He died later that day at 9:00 p.m.

Ms Linton blamed the delay in the transport of Mr. Anderson described to the hospital as “alarming”.

“I am satisfied that Mr. Anderson suffered a catastrophic stroke while in his cell and even with urgent medical treatment, he would not have been saved,” she said.

“Therefore, although the delay in getting him to hospital was concerning, it in no way caused or contributed to his death.”

Mr. Anderson died on 24 December 2020 at Kalgoorlie Health Campus. (ABC Goldfields: Elsa Silberstein) Death inevitable, say experts

Dr Sasha Rogers, a consultant neurologist at Sir Charles Gairdner Hospital, said Mr. Anderson’s postmortem imaging and clinical case reports reviewed.

He provided a brief report indicating that the delays in transferring Mr Anderson to hospital “would not have made any difference to the outcome”.

Professor Stephen Dunjey, the clinical director of the WA Country Health Service’s emergency department, noted that while the “delay in Mr Anderson receiving medical care is extremely regrettable”, it was not a contributing factor to his death.

The emergency department’s director of medical services, Dr Joy Rowland, told the inquest there was nothing anyone could have done to save him, and the same would have been the case even if he had been in hospital and could have been immediately specialist- undergoing neurosurgical treatment.

“There was evidence before me that the delay did not ultimately affect the outcome in this case as it appears Mr Anderson would not have survived even with quicker medical treatment,” Ms Linton said.

“I do not consider this to be the end of the matter, as the delay in opening the cell and calling an ambulance meant that Mr. Anderson’s cellmate in the distressed situation was left to a critically ill person on his own.

“There is also a real concern that if a similar situation occurs it could actually affect the outcome for another prisoner, so there is a public health interest in ensuring that night-time medical emergencies at the prison are managed appropriately .”

Save ‘life’ over ‘paperwork’

The inquest also heard that high staff turnover rates among EGRP prison officers, which was 123 per cent in 2020-21, meant it was a “nightmare” to ensure they were all up to date with senior first aid training.

There is also no nurse registered for the night shift at the prison.

Ms Linton made three recommendations during the inquest, including that the superintendent consider changes to existing plans for medical emergencies.

She said senior officers, especially on the night shift, must understand that “preservation of life is more important than completing paperwork”.

It was also recommended that the Department of Justice ensure that all officers have first aid qualifications.

“It is important that lessons are learned from this case so that when a prisoner experiences a medical emergency at night, they get appropriate medical attention as soon as reasonably possible,” Ms Linton said.

She also recommended that the Justice Department consider developing a formal online course for senior prison officers aspiring to supervisory roles to complete at their own pace while learning practical aspects of the job on the job.

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