Two nurses have been told to apologise for inadequate care of a prison inmate who died in 2011 after suffering seizures in prison.
Photo: RNZ
Details of the case were released today by Health and Disability Commissioner Anthony Hill after a request by RNZ News under the Official Information Act (OIA).
In his report, Mr Hill said the inmate, who was generally healthy apart from asthma and eczema, experienced an unwitnessed blackout at an unnamed prison.
Several days later, the inmate - Mr B - asked a nurse for a check-up as he was feeling unwell. She gave him an incomplete assessment at the prison clinic and decided he did not appear unwell, but booked him to see a doctor six days later.
At that visit, a GP ordered a thyroid scan and a full blood count, and the unnamed nurse took the blood sample several days later. Mr Hill's report said the nurse told the inmate at that point that she would review him that afternoon, but that never occurred.
This was despite Mr B having a headache and vomiting that day.
Around 10pm, two other unnamed nurses were also asked to check on the inmate, and one assessed him in his cell, noting that he had recently had a seizure and had a lump on his forehead but was feeling a lot better and was coherent.
However, at 11.15pm Mr B had another seizure, then a third seizure at 11.30pm. Mr Hill said Mr B became unconscious and stopped breathing, and two ambulances were called.
Mr B was taken to hospital where he had more seizures over the next four days and died.
The inmate's father complained to Mr Hill, saying his family had lost a valued and loved member, and this had caused him great unhappiness and financial hardship, because "Corrections just didn't care enough".
In his report, Mr Hill said there was incomplete documentation and he did not accept a statement by the first nurse, referred to as RNC, that she had checked out the man's pupils, breathing, pulse and skin colour after he reported the first seizure.
He also said RNC should have had Mr B seen by a doctor earlier than he was, and she should have asked someone else to review him if she was unable to.
He said, in failing to seek a medical review for Mr B, another nurse (RND) also failed to provide services with reasonable care and skill.
Mr Hill said the Corrections Department did not breach patient rights and he was satisfied that, in general, Corrections had appropriate systems in place to enable the provision of adequate care to Mr B.
However, he said it was suboptimal that RND was unable to look at Mr B's pupils in his cell late on his last night in prison, because there was no torch available.
But Mr Hill said the nurses' mistakes were individual failings and Corrections was not liable.
Nevertheless, he said Mr B was reliant on custodial staff to ensure he received health services.
He was concerned about Mr B's final night in his cell: "when custodial staff attended to Mr B at 11.30pm, there was a 24-minute delay between when custodial staff unlocked Mr B's cell and when an ambulance was called at 11.54pm. This is particularly concerning given Mr B's comments to custodial staff that he could not move or stand, and his subsequent seizure".
Following the approach from RNZ for his report under the OIA, Hr Hill said the opinion was not published as normal as he did not usually name healthcare providers who had not been found to have breached the patient rights code - and it was likely Corrections would be identifiable.