Inmate Nick Evans should have been taken straight to hospital, inquest told
An Auckland prisoner suffering respiratory distress should have been taken to hospital sooner, an inquest into his death has heard.
Nicholas Julian Evans, known as Nick, was allegedly injured in a fight at Auckland's Mt Eden Corrections Facility in March 2015, but did not officially report it to staff.
Two months later he was transferred to Northland's Ngawha Prison (NRCF) but only stayed one night before he was taken to Whangarei Base Hospital with chest pains.
He died three weeks later after being put in a medically induced coma to help him with breathing problems.
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On Friday, the hearing was told Department of Corrections clinical quality assurance advisor, Linzi Sargent, reviewed Evans' healthcare at MECF and NRCF before his death.
Evans' oxygen reading at NRCF was low, his breaths were rapid and shallow and nurse Patricia Sigley told the inquest on Thursday that his fingernails were blue.
Sargent said those oxygen levels indicated respiratory distress, requiring immediate intervention, and it would have been appropriate for Sigley to call an ambulance to take him straight to hospital.
Sargent also found the nurse's referral letter to Whangarei Hospital lacked two pieces of substantive information.
"Mr Evans' electronic clinical record described a traumatic injury to his spine and shoulder area in March, as a result of a fight at MECF, and the recent information where he described he was 'thrown against the bars at MECF '..."
"The discharge summary from Whangarei Hospital stated 'no antecedent trauma to the chest'. This was not accurate," the investigation found.
However, an autopsy found no chest trauma.
Sargent also found there was a lack of clinical information on the Custodial Management System (CMS) at MECF, with no nursing assessments, co-ordination and continuity of care and little or no documentation to support if or why a follow up had not occurred in Evans' case.
It was noted in the electronic clinical file that Evans' Medical Improvement Outcome (MIO) was not on his file, meaning MECF did not have access to his health information, Sargent said.
Dr Erna Meyer, a intensivist doctor at Whangarei Hospital, said Evans would have survived if he had not developed the superbug MRSA.
Meyer said she found no bruising or abrasions on Evans' chest and there was no evidence of trauma.
She told the inquest Evans would have had a higher risk of contracting MRSA as he was a prisoner.
"I was very distressed ... I thought he was young and thought he had a good chance of recovery," Meyer said.
Earlier in the hearing, a Corrections officer whose duties included transporting prisoners, said he first saw Evans on the morning of May 30, when Evans was lying on his side on the floor of a prison block reception area.
Evans told the officer he was in pain and had been in a fight at MECF where he landed hard on his back.
"I half-carried him to the medical centre."
The officer then took Evans to the doctor and later to Whangarei Hospital, where he was told Evans had a collapsed lung.
The officer then went on leave for a couple of weeks and when he returned to the hospital Evans was on "death's door".
"From what I remember, he was a likeable young chap, I was blown away that he died. To be honest I was quite upset," he said.
The officer also assumed Evans had told a senior officer about the altercation at MECF.
"Had I known Nicholas hadn't said anything, I would have let somebody know," he said.
Prison inspector Colin Ropiha undertook an investigation into Evans' death in 2015 and a number of recommendations he made were adopted at MECF and NRCF.
"There is no evidence to suggest that Mr Evans was subject to being "dropped" (over a balcony) or having been associated with the "fight club" activities whilst he was in custody at MECF…" the report found.
However, Ropiha told the inquest some altercations were under-reported.
The report concluded there were delays in Evans' requests for health appointments at MECF and it took 17 days for him to be seen by a health professional.
MECF Health Services was ordered to review its practices to ensure prisoner requests were actioned within a reasonable timeframe.
Other recommendations made by Ropiha included ensuring all prisoners transported to NRCF received "face to face" inductions.
On Thursday, the inquest heard how Evans told a physiotherapist at MECF, he'd been in an altercation with an inmate on March 31 and was "spear-tackled" and "dropped to the ground".
Physiotherapist Patricia Beattie did not report it as she "assumed" Evans had sought other medical care before he visited her six weeks after the alleged altercation.
MECF was previously run by Serco. However, it lost the right to run the prison in 2015 following allegations 'fight clubs' were being run inside its walls.
On Thursday, former Serco transition director at MECRF, Clint Bambrick, read a statement by one of Evans' fellow inmates, who said he was always holding his chest.
"He got assaulted by Black Power prospects after getting some tattoos and not being able to pay up. That's when he went downhill," the prisoner said.
The inmate said Evans was holding his chest and was quite pale on day they were transferred to NRCF.
Former head prison nurse at NRCF, Patricia Sigley, told the inquest Evans visited her in "serious" pain.
Sigley, who is now retired, said he was grunting and groaning as the pain spasms hit him, and was holding his side.
She gave him tramadol after being advised by a doctor before he was transported out of the prison.
"[The doctor] could hear him in pain in the holding cell with the door closed," she said.
Sigley asked Evans if he'd fallen off a bunk or slipped on the floor – code for asking a prisoner if they'd been in a altercation.
He grunted in response, Sigley said.
"He never mentioned anything about fighting ... I've never yet had a prisoner admit they'd been beaten, they'd ... say they'd fallen."