Prisoner's death in custody preventable, NSW coroner finds, recommending staff reviews

A New South Wales coroner has recommended that the conduct of medical staff be reviewed by professional councils after they failed to adequately treat, transfer, or monitor a newly arrested prisoner who subsequently died in custody. The prisoner, Dictor Dongrin, died in the Clarence Correctional Centre medical unit cell the day after his arrest in June 2022.

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medical staff who failed to treat, transfer or monitor a newly arrested prisoner for alcohol withdrawal should have their conduct reviewed by professional councils.

Deputy State Coroner Rebecca Hosking found that Mr. Dongrin died "from cardiac arrhythmia in a state of alcohol withdrawal." She stated that "timely and adequate medical intervention could have prevented death." The inquest heard that no physical medical observations were made during the 21 hours leading up to his death, rendering his treatment "wholly inadequate." It is likely he had been deceased for up to two hours before resuscitation attempts were made.

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Mr Dongrin died "from cardiac arhythmia in a state of alcohol withdrawal … and that timely and adequate medical intervention could have prevented death".

"There is evidence of systematic complacency and incompetence," Hosking stated. She noted that despite Mr. Dongrin scoring an eight on a drug and alcohol scale, there was no appropriate consideration given to transferring him to a hospital. The coroner highlighted the "cruel irony" that Mr. Dongrin died in a clinical observation cell where no observations were actually taken.

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There is evidence of systematic complacency and incompetence.

The coroner recommended that the conduct of two nurses working at the jail be reviewed by the Nursing and Midwifery Council. Additionally, the actions of the specialist doctor overseeing drug and alcohol treatment at the facility should be referred to the Medical Council of NSW for review. Barrister Ian Fraser, representing Mr. Dongrin's family, attributed the failures to prison medical staff operating within a "system of apathy which created a lack of responsibility."

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Despite a score of eight [on a drug and alcohol scale] there was no appropriate consideration made to transfer Mr Dongrin to hospital.