The Coroners Court of Victoria has found that a prisoner who suffered a fatal medical episode in 2016 while in custody of Ararat’s Hopkins Correctional Centre did not receive adequate care.
Subscribe now for unlimited access.
$0/
(min cost $0)
or signup to continue reading
However, Coroner Rosemary Carlin could not find clear evidence that prisoner Damien Mark Nobile, born September 1978 and of no fixed address, would have survived if he had been checked on in a more attentive manner by Corrections Victoria healthcare contractor ‘Correct Care Australasia’.
Coroner Carlin stated in her findings, released this month, that Nobile “died unexpectedly in custody from acute epiglottitis” after being taken by ambulance from the prison to East Grampians Health Service on January 4, 2016.
Epiglottitis is when a cartilage flap across the top of the windpipe becomes inflamed and blocks airflow to the lungs.
Nobile also suffered from coronary artery atherosclerosis, heart disease from a buildup of plaque in the arteries that run to the heart, which was found to be a contributing factor to his death.
Nobile was taken to Ararat prison in December 2015 after violating parole.
He was sentenced to 12 years in jail in 2005 after stealing a police officer’s revolver and hijacking a taxi to escape being arrested over a string of burglaries.
Nobile fired the stolen weapon at Constable James Donovan, who had smashed his way through the taxi’s window in an attempt to stop the carjacking.
Constable Donavan narrowly avoided being shot in the face.
Nobile smoked 20 to 30 cigarettes a day and was being treated with painkillers for a sore throat.
A specialist medical practice unit of the Coroners Court reviewed the circumstances of Nobile’s treatment at Ararat prison’s secure medical centre after he complained of a sore throat, a bad taste in his mouth and difficulty swallowing at 2.42pm on January 4.
Nobile returned to his cell following a doctor’s exam but reported to prison staff at 8.20pm that his throat was swelling up.
A nurse examined Nobile through a trap door to his cell and asked if he had any allergies or had been bitten by a spider, to which he said no.
“The main issued identified was the nurse’s assessment at 8.30pm,” Coroner Carlin stated.
“It was unsatisfactory that the assessment occurred through the cell trap door without vital signs being taken. A more detailed clinical review was required.
“The nurse’s documentation of this attendance is very brief and does not reflect the two cell mates’ description of Mr Nobile’s state at the time.”
Nobile’s condition deteriorated over the next two hours and his cell mates told guards he was “getting cold and shaky” and had “started to freak out”.
Nobile was taken to the prison medical unit and and an ambulance was called at 10.25pm, which took him to EGHS as a Code 1 ‘lights and sirens’ incident.
Nobile went into cardiorespiratory arrest and died at 11.31pm after attempts at resuscitation failed.
“It is apparent that Mr Nobile did not receive that medical care to which he was entitled,” Coroner Carlin stated.
“However it is not clear whether a more thorough review at 8.30pm, or indeed, any different medical treatment would have altered his outcome.
“Given the review and improvements that have been implemented by Correct Care I am satisfied there is no need to make and recommendations in this case.”
The Coroner and Corrections Victoria expressed their condolences to Nobile’s family.
"Corrections Victoria welcomes the Coroner's findings and we extend our condolences to Mr Nobile's family,” a Corrections Victoria spokesperson said,
“As the Coroner notes, Correct Care has since implemented improvements to medical response processes at Hopkins Correctional Centre.
“As such, there has been no need for the Corner to make any recommendations in this case."
Ararat Prison has introduced a major response bag for nurses to take with them when they assess prisoners away from the clinic.
The bag was designed to be lightweight and easily carried and includes equipment for the nurse to perform clinical observations.
Correct Care has reiterated to nursing staff that they can request guards to open cells during observations.