Thread by @dhadjowa

Day 6 of the Coronial Inquest into the death in custody of Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta woman, Veronica Nelson resumes today at 11am.
Link to hearing: csvic.webex.com/csvic/onstage/…
#JusticeForVeronicaNelson

Yesterday the Court heard emotional evidence from Registered Nurse Stephanie Hills, who spoke of massive failings in the prison doctor's health assessment of Veronica Nelson, during which Veronica was too unwell to sit in the chair and was unable to walk across the room.

Ms Hills yesterday told the inquest that when she raised her concerns about Veronica Nelson's health and condition and advocated for her to be sent to hospital, "he [the doctor] said, I'm the doctor, I will make the decisions"
#JusticeForVeronicaNelson

Coverage of yesterday's evidence from Ms Hills about the prison doctor fabricating details in the health assessment, before sending Veronica Nelson into the prison's mainstream population where she later died in custody: sbs.com.au/nitv/article/2…
#JusticeForVeronicaNelson

Evidence from Stephanie Hills, the Registered Nurse who testified yesterday, will resume later today. This morning at 11am the Court will hear from Dr Alison Brown, Medical Officer, Correct Care Australia
#JusticeForVeronicaNelson

Dr Brown was the doctor on shift in the prison on 1 Jan 2020 - the day after the prison reception medical assessment about which RN Hills gave evidence yesterday - and 2 Jan. Veronica died in custody and was found by prison staff in her cell early on the morning of 2 Jan 2020.

Counsel Assisting the Coroner commences questioning Dr Brown, who gives evidence that this was her first time working at Dame Phyllis Frost Centre (DPFC), and testifies that she recalls that Veronica was being held in a cell on her arrival to the prison
#JusticeForVeronicaNelson

Dr Brown gives evidence that there were no other doctors on shift, and that she had access to the electronic JCare prisoner medical file (with notes from Dr Runacres' reception medical assessment of Veronica when she entered the prison) & was spoken to by one of the nursing staff

Asked about the electronic prisoner medical file, Dr Brown confirms that the information she had access to prior to assessing Veronica Nelson included the entry by Dr Runacres 31 Dec, the entry made by the psych Nurse and the entry made by Ms Hills #JusticeForVeronicaNelson

Dr Brown testifies that she also received verbal info from Nurse Minett, "along the lines.. there was a patient in the cells who had had vomiting and diarrhea in the night...he might've indicated she was being treated for opiate withdrawal.. and might've suggested we review her"

Counsel Assisting (CA): Did he tell you how much she had been vomiting?
Brown: I don’t remember. I don’t think I had that because I haven’t written it anywhere.
CA: Did you also have access to the reception medical assessment by [Dr] Runacres?
Brown: Yes

Dr Brown gives evidence that she likely would also have looked at the JCare observations screen of the electronic medical file

Moving to her first assessment of Veronica, in the DPFC cells, Dr Brown says, "when I first assessed her it was Mark (Nurse Minett] and Corrections staff who helped open the door and brought her a drink. I can’t recall if I spoke to them on the way."
#JusticeForVeronicaNelson

CA: You were aware that she had been vomiting the day before?
Dr Brown: Yes
CA: And vomiting overnight?
Dr Brown: Yes that’s what she told me
#JusticeForVeronicaNelson

CA: And was that reported to you in anyway other than by Veronica herself?
Dr Brown: Yes I understood that [Nurse Minett] had got handover from the nighttime nurse looking after her that she had vomiting and diarrhea and that’s why he reported to me and why we reviewed her

The witness is asked about whether there are systems in place to monitor vomiting by prisoners [as a measure of things like dehydration]
CA: Was there a system in place that recorded each time a patient held in the health centre vomited?
Dr Brown: Not that I am aware of

CA: If a patient was in hospital rather than held at some other facility would frequency of vomiting be recorded in a chart or somewhere?
Dr Brown: I’m trying to recall... Generally I think a lot of wards these days have those kinds of charts, but I can’t really recall, I'm sorry

CA: The frequency and amount vomited by a patient tells you important information about how sick they are?
Dr Brown: Yes it does, indeed
CA: It would be prudent to have that information recorded if they were in hospital?
Dr Brown: Yes

Asked if a record of the frequency and amount vomited by a patient is important because it "particularly gives you information about what their level of dehydration might be," Dr Brown responds, "yes, it’s useful information."
#JusticeForVeronicaNelson

Counsel Assisting: Did you know that she had asked to see the doctor 5 times between 9:30am and 10:45am
Dr Brown: No I didn’t
#JusticeForVeronicaNelson

The Court is then shown CCTV footage of Dr Brown's first assessment of Veronica Nelson at 10.48am. This footage runs for 7 mins and the medical assessment takes place in the cell where Veronica is being held
#JusticeForVeronicaNelson

The Court hears that assessments of patients is normally undertaken in a treatment room, not a cell.
CA: Do you think it was because she wasn't well enough to be taken down to the treatment room?
Dr Brown: I am not sure.. I don’t know, I didn’t question why we didn’t go in there

The Court sees footage of the medical assessment of Veronica in the cell, including an abdominal examination.
CA: When you were in there undertaking her assessment did you see vomit on her blanket
Dr Brown: No…
CA: Or anywhere else in the room?
Dr Brown: No

Taken to a copy of her JCare notes, Dr Brown agrees that these state, "multiple vomits overnight, diarrhea, no blood."
CA: You had been told about the vomiting by MM and Veronica had reported to you that she had been vomiting
Dr Brown: Yes [nodding]

CA: Can you say what is the impact of repeated vomiting on the body & the complications that can flow from that?
Dr Brown: Vomiting means you're losing fluids and also you can be losing electrolytes. The compilation is that you can become dehydrated & get electrolyte imbalance

CA asks Dr Brown if she found Veronica to be dehydrated
Brown: Yes I did think she was somewhat dehydrated… She had a dry tongue...She was also tachycardic [fast heart rate] and I attributed that to opiate withdrawal... but it also could have been contributed to by dehydration

CA: We have a no. of med experts who've provided reports for this inquest. Dr Fray gives the opinion that frequent vomiting is uncommon of withdrawal
B: I don’t know. I am not an expert in the area. I don’t know what rate of vomiting would be considered consistent w withdrawal

We are told that in Dr Brown’s notes of her assessment of Veronica she records that Veronica has a heart rate of 123 BPM

CA: Is that a rapid heart rate?
B: Yes it is fast
CA: Particularly for a person who is at rest when it is taken
B: Yes
#JusticeForVeronicaNelson

CA: Do you agree that this degree of tachycardia [rapid heart beat] for a person at rest is particularly concerning for a person who is as thin (33kg) as Veronica was?

B: I am not sure I took that into account...Maybe it is more concerning

#JusticeForVeronicaNelson

CA makes ref to expert report of Dr Clark who gives the opinion that this degree of tachycardia (referring to HR 123) usually indicate significant medical problems needing immediate medical attention even more so for someone of Veronica weight (33kg)

#JusticeForVeronicaNelson

CA: You were aware that she had a HR registered at 57 BPM at 5:54 the day before
B: I saw in notes and thought it was interesting...I think I thought perhaps opiate withdrawals were more severe at this point
CA: 57 to 123 is that not an extraordinary rise in HR?
B: I agree it is

CA: Do you agree opiate withdrawal can be fatal?
B: ...I understand it’s quite rare to be fatal
CA: Do you understand why it can be fatal
B: I am not sure I know the exact mechanism. I think it would be to do w significant diarrhoea & vomiting causing electrolyte disturbance

CA: Was that something you were alert to when you saw Veronica?
B: I don’t think I put her in a high risk category, but I was aware she had symptoms that were concerning. I don’t think I had the concept that opiate withdrawal could be fatal central to my thoughts, no

CA described video footage of Veronica vomiting, (sometimes in a projectile fashion) 4 times in a 1 hour and 20 min window at night, and then another 4 times in the early hours of the following morning.

#JusticeForVeronicaNelson

CA: If you had that info about Veronica, would you have seen to it that she received IV hydration fluids?

B: I recognise now that’s very significant. It sounds like 7 vomits, and some of them quite wild, so if I had that info available to me it would have come into my judgement

CA: If IV rehydration wasn't available inside the prison, would you have sent her to hospital in order for her (Veronica) to receive it?

B: Yes of course I would have if I thought that was necessary

The court is shown footage of the second medical consultation that Dr Brown has with Veronica in the cell she is being held in.

Veronica can be seen lying curled on her side on the mattress in the cell, with a vomit bag on the ground.

#JusticeForVeronicaNelson

CA: Is it fair to say that she [Veronica] doesn't look better there than she did before?

B: I would agree, yes

CA: Were your concerns about Veronica’s health increased after this second assessment?

B: I was concerned she’d had another vomit

#JusticeForVeronicaNelson

CA notes that Veronica lay down curled up for the entire time Dr Brown conducted the 2nd med assessment. CA asks if this lead to increased concern

B: I can’t remember at the time if I placed significance on this. I agree w you this could mean she was feeling more unwell

We hear that Veronica vomits 2 more times over the next hour

CA: Do you think if you had been provided the detail of the no. of times she had vomited that you would have had her sent to hospital?

B: Yes i think so...I would have sent her to hospital if i had that info

CA: I asked you earlier whether [no. of vomits is recorded]...and you said some places and not everywhere. Do you agree in relation to Veronica it would have made a difference to her electrolytes and hydration..?

Brown: Yes, I agree it would have made a difference

CA goes through Dr Brown’s notes on ‘bedside investigations’ in Veronica' treatment plan.

CA: Did you not change the med regime provided by Dr Runacres the day before?

B: I did. I changed the form of anti-vomiting med to intramuscular form as its more easily absorbed that way

We are told that Dr Brown requested bloods tests.

CA: Did you ask for these to be done ASAP?

B: Yes...but I was told it was a public holiday and they couldn't be done that day. I didn’t think this was ideal, I thought they should have been done that day, but I accepted this

CA: In terms of Veronica's presentation was it ideal that she wait for test results?
B: It would have been worthwhile having access to her blood test results
CA: Is it right that the only way that could have happened is if she was sent to hospital?
B: Yes, that’s probably right

CA: Corrections usually do prisoner management, but on health and decisions available to you, do you agree you could have insisted on her (Veronica) going to hospital?
B: I could have
CA: That was clearly in your power and you understood that
B: Yes
#JusticeForVeronicaNelson

1/2
CA: ​Should you have exercised your power to have Veronica taken to hospital?
B: …I regret everyday I didn’t send her to hospital and ensure she received that standard of care. Knowing then what I know now.. but at the time I didn’t know this...

#JusticeForVeronicaNelson

2/2
B: I didn’t know what the cell she was going to be like, I assumed she would still be able to be observed by prison staff.. I...assumed that if she had further vomits, she would have been able to report them. If she had other symptoms, ask for help
#JusticeForVeronicaNelson

CA: When you assessed her (Veronica) were you aware that she had used her intercom 30 times the preceding night asking for help?
B: 30 times before I saw her?
CA: That’s right
B: No I didn't know that, that’s a very big number.
#JusticeForVeronicaNelson

Brown gives evidence about the limitations on prescribing particular meds and the “constraints on medical practice” in prison. We are told Veronica was prescribed suboxone but had expressed that she wanted to be on methadone

CA: You weren't able to prescribe methadone?
B: No

CA: I put to you earlier that Suboxone is a withdraw treatment. But can I ask you if suboxone can be used as a replacement treatment if it's provided at a higher dose?

B: Well yes, I put both suboxone & methodone as opioid antagonists, meaning they do act as opioid sub therapy

CA: So if you had, would you have been empowered to increase the dose of suboxone to Veronica?

B: Was I empowered? No i couldn't have changed the dose. If i was empowered, would I, yes

#JusticeForVeronicaNelson

CA: Is that because it would have alleviated the symptoms for her?

B: Yes, people can get better relief of symptoms w higher doses..

#JusticeForVeronicaNelson

CA: Could alleviating some of the symptoms of her withdrawal affected whether or not she passed away?

B: I don’t know if I am an expert in what she passed away from and that area, so I might leave that comment for an expert in that area if that’s okay

#JusticeForVeronicaNelson

CA: Could increasing the dose of suboxone improved her condition in relation to her heart condition & hydration?

B: Potentially, yes...I’m just making a best guess. Higher doses can alleviate symptoms better than lower doses. So she may have had less vomiting & diarrhea...

1/2

CA: If through whatever means Dr Brown you were able to alleviate some of Veronica’s symptoms of heroin withdrawal, would you expect any other physical problems that existed for her might then more readily appear or be apparent?

2/2

B: Yes, I think that would be clear. As I described, I thought the most likely diagnosis picture of presenting symptoms was opiate withdrawal. Later, I understand she had another...complicating condition. So yes I think having withdrawal symptoms did mask other conditions

Counsel for Aunty Donna, Veronica’s mum, is now questioning the witness.

While Dr Brown had previously worked at other correctional facilities, Jan 1 was her first day working at DPFC. She is q'd about whether she made assumptions about DPFC being similar to other facilities

Dr Brown: I thought it'd be similar to other facilities...I don’t know why. I had an understanding other cells would look similar, windows, staff around and patients could ask for help if needed

#JusticeForVeronicaNelson

Counsel makes ref to med notes from the psychiatric nurse and Dr Runacres

Dr Brown formed the view that GP notes that Veronica “seemed generally well” contradicted the psychiatric nurses more detailed notes

B: they didn't seem to concur with the clinical picture and 2 sides

Stephanie Wallace, Counsel for Percy Lovett is now asking qs

The witness is asked about Indigenous over-incarceration

B: I knew that fact..it was something I was concerned about when I came to work in the prison…

#JusticeForVeronicaNelson

The witness is asked about Aboriginal Deaths in Custody

Dr Brown, notably upset and crying:

Yes I am aware, and I am very concerned about this… I want to say that I am really very sorry to Veronica’s family and her community.

#JusticeForVeronicaNelson

Counsel for Brown is asking qs. He asks about her tears

B: The passing of Veronica is…upsetting…I don't want to talk about how it’s upsetting for me as I am not her family or her community. But yes, its my sadness at her passing & importance of events over those days

Court is adjourned until 10am tomorrow

Tomorrow nurse Stephanie Hills will be cross examined by other parties

Dr Runacres, the Dr who initially assessed Veronica when she arrived at DPFC and elected not to send her to hospital will also give evidence

#JusticeForVeronicaNelson

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