Deputy Health and Disability Commissioner Kevin Allan today released a report finding a doctor, nurse and the Department
of Corrections in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for providing
inadequate care to a woman in a correctional facility.
The woman had a diagnosis of irritable bowel syndrome when she arrived at the correctional facility. A few months later
she reported symptoms which included a burning throat, a sore right ear, an inability to hold down food,
light-headedness, weakness, having too much gas in her stomach and waking with acid in her mouth. Over the next
approximately two months the woman reported health concerns relating to nausea, reflux and vomiting on a number of
occasions by submitting health chits or attending the nursing clinic as a walk in. She was seen by nurses on a number of
occasions. She was also seen by two different doctors and prescribed medications to decrease stomach acid production and
to relieve nausea and vomiting. The second doctor who saw the woman after around seven weeks queried a diagnosis of
inner ear inflammation.
When the woman reported black matter in her vomit a nurse scheduled her for review the next morning at which point the
woman was transferred to hospital. Investigations revealed advanced gastric cancer and she later died.
Mr Allan considered that by failing to adequately take account of the woman’s symptom history, and by failing to perform
an appropriate clinical examination, the second doctor failed to provide services to the woman with reasonable care and
skill.
Mr Allan considered that the nurse’s response to the woman’s report of black vomitus was seriously deficient, and that
by failing to respond with the required urgency, the nurse failed to provide services to the woman with reasonable care
and skill.
Mr Allan considered that the pattern of failures by multiple staff indicated broader systems issues and found that the
Department of Corrections also failed to provide services to the woman with reasonable care and skill. Those failures
included a lack of appropriate assessments and physical examinations, inconsistent documentation and poor coordination
of care. Mr Allan was also concerned about the lack of critical thinking by staff in that no nurse appeared to have
looked at the overall picture, despite the woman raising health concerns on a number of occasions. He considered that
the number of failings in the care provided indicated an environment that did not support its staff adequately to do
what was required of them.
Mr Allan recommended that the nurse and the Department of Corrections provide a written apology to the woman’s family.
The doctor provided an apology in response to a recommendation in Mr Allan’s earlier provisional opinion.
In response to recommendations made in his provisional opinion, the Department of Corrections provided evidence of staff
training and undertook to arrange for education of its staff on commonly presenting health conditions by an independent
nursing educator. Mr Allan also recommended that the Department of Corrections conduct an audit of documentation.
The Department of Corrections was referred to the Director of Proceedings.
The report for case 16HDC01703 is on the HDC website.