Inquest into the death of Peter Gretton

Case Number: 2019/2380

Findings Date: 1 August 2023

Magistrate: Derek Lee

CORONIAL LAW | death in custody; cause and manner of death; metformin toxicity; renal impairment; care and treatment of inmate patient; vital sign observations; blood glucose level test; recognition of deteriorating patient; communication between clinicians; escalation of care, pathology collection and results; Health Practitioner Regulation National Law (NSW)

Responses

Recommendations

GEO Group Australia Pty Ltd

1. I recommend to the Managing Director, the GEO Group Australia Pty Ltd, that consideration be given to the following matters:

(a) amending the Pathology Services Policy (MP334) to provide that pathology requests are to be reviewed weekly by clinical staff to ensure that results are obtained in a timely manner, consistent with pathology service expected turnaround times, and that senior nursing clinicians are to be advised of any outstanding result of more than seven days so that the pathology request can be escalated;

(b) formulating a list of presenting symptoms or vital sign observations in a patient that will cause a nursing staff member at Junee Correctional Centre to automatically request review of the patient by a medical officer, whether during hours or after-hours;

(c) providing further education and training to nursing staff at Junee Correctional Centre to ensure competency regarding use of the i-STAT machine, and for these skills to be audited;

(d) conducting an audit of patients presenting to the clinic at Junee Correctional Centre to ensure that vital sign observations are being taken in accordance with the Recognition and Management of the Deteriorating Patient Policy; and

(e) ensuring that clinical staff are appropriately trained regarding how care for a patient may be escalated if one or more of the patient's vital signs are documented to be in the Yellow Zone.

Nursing and Midwifery Council NSW

2. I recommend, pursuant to section 151A(2) of the Health Practitioner Regulation National Law (NSW), that a transcript of the evidence of Registered Nurse Loice Magazini given during the Inquest into the death of Peter Gretton be forwarded to the Executive Officer of the Nursing and Midwifery Council New South Wales.

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