A West Australian coroner says senior staff at a regional prison need to understand that preservation of life is more important than the completion of paperwork.
Deputy Coroner Sarah Linton made the observation while delivering her findings into the death of 48-year-old Mr Anderson, as he is known for cultural reasons, from a "catastrophic" stroke at Eastern Goldfields Regional Prison (EGRP) in 2020.
But Ms Linton stopped short of blaming prison and hospital staff for Mr Anderson's death.
She found he had no chance of survival, despite being forced to wait more than two hours for emergency medical treatment.
Mr Anderson was serving a six-month sentence for traffic offences when he collapsed in his cell on December 23, 2020.
He died the next day from an "unsurvivable" intracerebral haemorrhage, or haemorrhagic stroke, which is bleeding inside the brain caused by the rupture of a blood vessel.
The inquest heard Mr Anderson had been in custody since November 24 and that he was an alcoholic who had multiple health conditions, including high blood pressure and diabetes.
Mr Anderson's cellmate reported he had collapsed at 10.20pm on December 23.
"Miss, please get a doctor. Please. He has blacked out. Hurry miss, get a nurse," Mr Anderson's cellmate "Jason" was recorded as saying on the prison intercom.
When prison officers arrived at the cell nine minutes later, Mr Anderson was still conscious and talking, but had visible weakness on the left side of his face.
Officers followed protocol by contacting the on-call doctor while they communicated with Mr Anderson and his cellmate through an observation hatch.
They did not open the cell door until 10:45pm, after conducting a risk assessment in line with their training.
At some stage Mr Anderson coughed up a lot of dark, red blood.
St John Ambulance was not contacted until 11:05pm.
The ambulance arrived at the prison at 11:20pm and left the unit with Mr Anderson at 11:40pm, but did not depart the prison until 12:16am because paramedics waited more than half an hour for prison officers to fill out transfer paperwork.
During that time Mr Anderson was placed in restraints and prison officers collected an escort vehicle.
Two hours from collapse to hospital
The inquest heard Mr Anderson arrived at the emergency department of Kalgoorlie Health Campus at 12:25am.
He was triaged as a category 3 patient – to be seen within 30 minutes – and was diagnosed with a likely stroke after being examined at 12:36am.
The inquest was told Mr Anderson's condition continued to deteriorate and a head CT scan performed at 1:40am showed a very large acute cerebral haemorrhage with surrounding brain oedema.
Mr Anderson's case was discussed with neurosurgeons at Royal Perth Hospital, who advised he was not suitable for surgical treatment and should be managed palliatively.
He died later that day at 9pm.
Ms Linton described the delay in transporting Mr Anderson to hospital as "concerning".
"I am satisfied that Mr Anderson suffered a catastrophic stroke while in his cell and even with urgent medical treatment, he would not have been saved," she said.
"Therefore, while the delay in getting him to hospital was concerning, it did not cause or contribute to his death in any way."
Death unavoidable, experts say
Dr Sasha Rogers, a consultant neurologist at Sir Charles Gairdner Hospital, reviewed Mr Anderson's post-mortem imaging and clinical case reports.
He provided a brief report indicating that in his opinion, the delays in transferring Mr Anderson to hospital "would have made no difference to the outcome".
Professor Stephen Dunjey, the WA Country Health Service emergency department clinical director, noted that while the "delay to Mr Anderson receiving medical care is extremely regrettable", it was not a contributor to his death.
The emergency department's director of medical services, Dr Joy Rowland, told the inquest there was nothing that anyone could do to save him, and the same would have been the case even if he was in hospital and able to immediately undergo specialist neurosurgical treatment.
"There was evidence before me that the delay did not ultimately affect the outcome in this case, as it would seem Mr Anderson would not have survived, even with more prompt medical treatment," Ms Linton said.
"I do not consider that to be the end of the matter, as the delay in opening the cell and calling for an ambulance to attend meant that Mr Anderson's cellmate was left in the distressing situation of trying to care for a critically ill person on his own.
"There is also a real concern that if a similar situation occurs, it might actually affect the outcome for a different prisoner, so there is a public health interest in ensuring medical emergencies at night at the prison are managed appropriately."
Preserve 'life' over 'paperwork'
The inquest also heard that the high staff turnover rates among EGRP prison officers, which was 123 per cent in 2020-21, meant it was a "nightmare" to ensure they were all up to date with senior first aid training.
There is also no nurse rostered on for the night shift at the prison.
Ms Linton made three recommendations at the inquest, including that the superintendent consider amendments to existing plans for medical emergencies.
She said senior officers, particularly on the night shift, should understand that "preservation of life is more important than completion of paperwork".
It was also recommended that the Department of Justice ensured all officers had first aid qualifications.
"It is important that lessons are learnt from this case so that when a prisoner suffers a medical emergency at night, they get appropriate medical help as soon as reasonably possible," Ms Linton said.
She also recommended that the Department of Justice consider developing a formal online course for senior prison officers who aspire to supervisory roles to complete at their own pace while learning practical aspects of the position on the job.
