Kenneth Wright was a 71 year old man who was detained at the Southern Queensland Correctional Centre at Spring Creek. While in detention, Mr Wright was found by nursing staff in a deteriorating state with oxygen saturations of 77 percent.

He was left unattended and approximately one hour later was found deceased in his cell. Mr Wright had previously sustained significant head injuries while detained at Capricornia Correctional Centre in September 2014.

Background Facts

Kenneth Wright was a 71 year old man who, at the time of his death, was a prisoner at the Southern Queensland Correction Centre (SQCC). He had been imprisoned since 2013. He had a moderate cognitive impairment as a consequence of injuries sustained at the Capricornia Correctional Centre in September 2014.

In September 2014, just over 6 months before his death, Mr Wright had been seriously injured as a result of a fall from a balcony. His injuries included subarachnoid haemorrhage. The incident was assessed as an attempted suicide. As a result of his injuries, Mr Wright was bedridden in his cell at the Southern Queensland Correction Centre's Advanced Care Unit at the time of his death in March 2015. He was also the subject of a guardianship order.

Mr Wright had been transferred from Rockhampton to the Princess Alexandra Hospital Secure Unit in Brisbane. He was then discharged to SQCC, where he received ongoing medical management. Mr Wright required assistance with activities of daily living, and could not participate in rehabilitation.

At 1:33pm on the afternoon of 20 March 2015 Mr Wright was found by nursing staff in his cell in a deteriorating state with oxygen saturations of 77 percent. Although his oxygen saturations were below 80 percent he was not provided with supplemental oxygen or increased observations. He was left unattended and was found deceased in his cell at 2:40pm. An acute resuscitation plan was not in place at the time of his death.

Findings

The State Coroner Terry Ryan found that, at the time of his death, Mr Wright was a 'chronically unwell man with multiple comorbidities and no prospect of significant improvement in his health'.

The inquest concluded that the care provided to Mr Wright in the ACU at the SQCC was generally of a high standard. However, the response to Mr Wright's deteriorating state on 20 March 2014 should have been to provide supportive oxygen as a matter of urgency while requesting assistance from the QAS and the VMO. The failure to do so was not consistent with good nursing practice.

The Coroner considered that the failure to provide an observations regime between 1:33pm and 2:40pm represented a failure to respond to the diminishing oxygen saturation levels in a timely way. The Coroner noted that the precise role that lack of observation and the delayed arrival of an ambulance for transfer to hospital played in Mr Wright's death was indeterminate. It was possible that those factors may not have influenced the outcome in light of Mr Wright's comorbidities. Nevertheless, supplemental oxygen would likely have assisted to stabilise his condition.

The Coroner concluded that when Mr Wright was found unresponsive, suitable actions were taken by the nursing staff to review Mr Wright’s vital signs and the decision that CPR efforts at that stage would be futile was appropriate in the circumstances.

The Coroner noted the steps taken by the SQCC operator since Mr Wright's death, and was satisfied that those steps will help prevent a death in similar circumstances. He made various recommendations, in particular that the SQCC operator and Queensland Corrective Services conduct a review of the process for calling for ambulance attendance at SQCC, and the priority given to those requests.