An Aboriginal man who was in cardiac arrest for two days while in a Darwin prison received suboptimal healthcare and his death could have been avoided, a coroner has found.
On Wednesday, Northern Territory Coroner Elisabeth Armitage delivered her findings into the death of Glen Dooley, 37, in October 2022.
Mr Dooley had been serving a six-month prison sentence for assaulting his former partner by pulling her hair and throwing her to the ground.
The father of two was a Mayali man who spent most of his life in Manyallaluk, on Jawoyn country, 100km northeast of Katherine.
He had spent almost seven years in custody between 2004 and 2022.
Mr Dooley had a history of chronic heart problems and was diagnosed with high cholesterol and hyperlipidaemia while in custody in 2014.
Judge Armitage found that abnormal results from an electrocardiogram (ECG) conducted while Mr Dooley was in custody in June 2019 should have led to a referral to a cardiologist.
"Further assessment by a cardiologist would have revealed blockages in the arteries of his heart," she wrote.
She noted that NT Health had conceded that the failure of medical staff to adequately review and refer Mr Dooley to a cardiologist were "serious and significant shortcomings in the care provided to him".
In June 2022, he underwent an initial custody health screening at Darwin Correctional Centre and on September 13, a routine ECG produced abnormal results.
A prison doctor requested a recall for the following day and recommended a cardiologist referral.
The administrative entries were made by a nurse but the high-priority recall box was not ticked.
Cardiologist Kenneth Hossack told the inquest in January that "at a minimum, the person recording the ECG should have discussed it with a cardiologist … (because) there was evidence of ischemia, or not enough blood supply to the heart occurring at that point in time".
Due to competing demands on the prison clinic and the triaging of recalls, Mr Dooley was not recalled until September 26, by which time he was already experiencing a cardiac event.
"Dr Hossack opined that had Mr Dooley been seen by a cardiologist on September 13, there is a 50 per cent probability that he would have survived," Judge Armitage wrote.
"The evidence established that there were repeated, and likely systemic, failings to recognise and appropriately respond to Mr Dooley's abnormal ECGs.
"I consider that the circumstances of Mr Dooley's death were avoidable, the more so, if his ECG had been properly understood on September 13, or his deteriorating condition had been correctly identified on September 25. I accept Dr Hossack's opinion that the care that he received was suboptimal."
Mr Dooley underwent surgery at Royal Darwin Hospital, revealing he had been in cardiac arrest for more than 48 hours.
After a failed attempt at heart surgery in Adelaide, he was flown back to Darwin and died on October 22, 2022, surrounded by family. He died of complications of ischemic heart disease with high cholesterol deemed a contributing factor.
Judge Armitage recommended that NT Health implement reforms including procedures for ECG management, review and referral in Prison Health, and procedures to ensure timely recall of patients.
She also recommended that NT Corrections implement reforms including establishing a procedure to ensure direct phone or video contact between prisoners and medical staff, and a review of the current prison diet to determine whether it is suitable for prisoners with high cholesterol or cardiac risks.
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