Inquest into the death of Danny Keith Whitton

Case Number: 2015/329568

Date of Findings: 19 November 2021

Magistrate: Deputy State Coroner, Magistrate Elaine Truscott

Catchwords: CORONIAL LAW – Cause and manner of death - death in custody - First Nations Prisoner- paracetamol toxicity- care and treatment- delay-CCTV

Responses

Recommendations

To GEO Group Australia Pty Ltd:

1. Ensure that training occurs so that all health staff are aware that nurses can call an ambulance to transfer a prisoner without a doctor’s authorisation. 
2. Ensure that GEO Health Service policy accurately reflects the importance of regular monitoring and notation, recognition of signs of deterioration inpatients 78 and clear procedures for escalation for the particular facilities that exist at the Junee Correctional Centre health clinic. 
3. Provide training to health staff and corrections staff about the permissible collection, use and disclosure of health information.

To Justice Health and Mental Health Forensic Network:

1. Provide training to staff which identifies and raises awareness that paracetamol overdose can occur as a result of excessive consumption of paracetamol. 
2. Develop an information sheet for health and correctional staff which will prompt staff to inquire with an inmate as to the quantity of paracetamol ingested when they present and provide pathways for staff to take regarding any paracetamol overdose. 
3. Conduct a review of the Paracetamol Consumer Medicines Information to ensure it includes a warning about the misuse or overdose of paracetamol, the risk of harm and the range of possible symptoms and an indication as to when a person should seek medical attention.

Corrective Services NSW:

1. Provide training to staff which identifies and raises awareness that paracetamol overdose can occur as a result of excessive consumption of paracetamol. 
2. Provide information to inmates which identifies and raises awareness that paracetamol overdose can occur as a result of excessive consumption of paracetamol. 
3. Implement policy and practice to retain a copy of CCTV footage capturing the last 7 days of movements of a person who has died in custody and only release such footage upon an indication by a senior coroner that such footage is no longer required for the coronial investigation and inquest.