Thread by @dhadjowa

Today is day 9 of the coronial inquest into Veronica Nelson's death in custody. Today the inquest will hear from Bester Chisvo, Forensicare Psychiatric Nurse who assessed Veronica in DPFC prison & Mark Minett, Registered Nurse, Correct Care Australasia #JusticeForVeronicaNelson

You can log in to the inquest livestream via this link: csvic.webex.com/csvic/onstage/…

#JusticeForVeronicaNelson

Ms Chisvo enters the witness box. Counsel Assisting commences questions as to Ms Chisvo's work history, and Ms Chisvo pauses answering to say, “I want to send my sincere condolences to the Family, I should have done this before I sat down”
#JusticeForVeronicaNelson

Ms Chisvo gives evidence on her role as the Psychiatric Nurse completing the prison psych assessment: "It is my role to assess if they need any extra help...for instance on substances...assistance w withdrawal… if they are at risk to themselves or others.... what help they need"

"When [prisoners] are ready for me to assess they are brought to me in a room... and I can conduct my assessment..
In this situation it was not possible for Ms Nelson to be brought into an interview room, I had to be brought into a holding cell because of how she was" - Ms Chisvo

Ms Chisvo, the Psyh Nurse who assessed Veronica: "The Sr [Corrections] Officer... asked me to come and see her because she wasn't able to come to interview room...

Part of my nursing training is to observe… as soon as I came to her I could see she was struggling physically"

Ms Chisvo gives evidence that usually she would receive background information, including about mental illness, from the police cells a person had been transported from. She states, "on this day I did not get this information [from police]"
#JusticeForVeronicaNelson

Counsel: Usually you would get handover info from police, do you know why you didn’t get this?
Chisvo: No, I don’t know why
Ms Chisvo explains it was the first week Forensicare had taken over reception [assessments] from Correct Care & says, "later we started receiving this info"

Describing seeing Veronica Nelson, Ms Chisvo says, "As I walked into the holding cell she was lying down... I went and introduced myself and why I was there...

She was very polite and cooperative, but she was physically struggling, she could hardly sit down and she was vomiting"

Prison Psych Nurse describes Veronica Nelson's condition, when she saw her in the holding cell as Veronica was too unwell to come to interview room, "In the time I spent with her.. 7 mins or so...she threw up three times, so that’s how unwell she was."
#JusticeForVeronicaNelson

"She [Veronica] looked very pale and somewhat malnourished... she told me she was not eating well due to addiction...I did not spend much time with her because of how she was struggling physically" - Ms Chisbo, Psychiatric Nurse
#JusticeForVeronicaNelson

Counsel: When you said v was obviously struggling?
Chisvo: She was lying on the mattress... Like I said, the expectation was for her to be brought to me in interview, but because she was physically not able to walk to me… I had to go to her #JusticeForVeronicaNelson

Describing trying to complete psych assessment with Veronica in the cell, Ms Chisvo said, "I asked her if she was able to sit up.. She said, 'no Miss..I feel horrible'.. for me actually seeing her vomiting, it was clear to me she was physically compromised in health at the time"

Counsel: In comparison to other patients?
Chisvo: I think she [Veronica] was the worst in terms of who was physically compromised on that day. I had seen 6 other women and she was the one who was physically unwell #JusticeForVeronicaNelson

Counsel: In comparison to women you see on an ongoing basis?
Ms Chisvo: To be honest, in all the receptions I have done I have seen [a number of] people withdrawing… but it was a significant level. #JusticeForVeronicaNelson

"I did recommend that she [Veronica] needed further exam given how she was presenting physically... I thought the medical doctor would do what needed to be done in their expertise, which is not my expertise...My role is to observe and recommend, which I did," said Ms Chisvo

[1 of 3] CA reads Chisvo her own comments which said she, “considered she [Veronica] would benefit from further review [psych] when she was orientated and alert…" and asks Ms Chisbo whether this meant Veronica was not orientated or alert at the time of her psych assessment

[2 of 3] Ms Chisvo responds, "although she was able to respond to q’s i was asking her...she was closing her eyes.. my obs was that she was not not fully orientated, so I was not comfortable that I got all I needed to in terms of her mental health"

[3 of 3] Ms Chisvo continues, "for instance, I asked her if she had been in inpatient care, she said no, but when I checked she had been in [hospital] twice...So she wasn’t able to recall that... In my opinion that was a gap." #JusticeForVeronicaNelson

"My assessment was v brief because of how she was presenting. When [Veronica] was in police holding cells that’s where assessment should have begun. But I wasn’t given that info & she told me she wasn’t given anything [to treat withdrawal]… that’s something that should've begun"

Chisvo (Prison Psych Nurse): "When someone is brought into police custody.. Based on how they are presenting there should be mental health nurses to assess...[Veronica] should have been given a withdrawal pack... medication to stop vomiting"

The court is shown footage of Ms Chisvo attempting the psych assessment in the cell, where Veronica is on the mattress. Veronica can be seen putting paper towel down over her vomit on the floor
#JusticeForVeronicaNelson

Asked about the part of the footage where Veronica returns to lying down at the end of Ms Chisvo's attendance in the cell, Ms Chisvo says, "“She .. lies down because she was physically unwell”
JusticeForVeronicaNelson

Asked what happened following her assessment of Veronica, Ms Chisvo explains, "ther isa form where we write whether the person needs to be placed on observation or level of mental illness. This form I give to senior [Corrections] officer on duty and explain condition.. "

The Court is shown a copy of the form, which shows My Chisvo's recommendations re Veronica after her psych assessment. The form reads: “Recommend she stays in medical due to severe heroin withdrawals” [Veronica was later released into & passed away in the mainstream prison unit]

Ms Chisvo gives evidence that at the time the prison medical centre would keep some women in medical overnight w overnight nurses and one CO: "We understood this was what was happening [w Veronica]

Asked about her recommendation that Veronica stay in medical, Chisvo responded: "In the many assessments I have conducted, she was one of the people who was really unwell.. The withdrawal was severe.. I felt she needed to stay in there and be observed"
#JusticeForVeronicaNelson

Asked about what she understood would be the effect of recommending on the form [given to Corrections Senior Officer] that Veronica stay in the medical unit, Ms Chisvo [psych nurse] answers:
"So they would act on what has been recommended"
#JusticeForVeronicaNelson

Counsel Assisting moves to questions of Ms Chisvo about her knowledge of a process whereby prisoner is “cleared for release”:
Chisvo: That is not something that is for Forensicare
C: Do you have any role in clearing prisoner to main area?
Chisvo: No

Counsel: Are you given any opp to give your views on whether a prisoner can leave medical?
Ms Chisvo [prison psych nurse]: No. When it comes to medical health I have no role..i it’s down to med staff to take further
#JusticeForVeronicaNelson

Asked about her role re prisoner's medical health, Ms Chisvo (psych nurse) responds: "This is where I explained if it was mental health I would do [mental health rec's].. in this case she was not suicidal.. my concern was for her physical health, not to do with her mental health"

Asked if she spoke to anyone else after seeing Veronica, Ms Chisvo said she spoke to the Sr Corrections Officer first, then spoke to medical officer [Dr Sean Runacres] re her assessment and medications (saying Veronica needed further obs) & that she spoke to nurse about her views

Asked about her conversation with Dr Runacres, Ms Chisvo responds: "This is diff for me to say. I don’t know whether it's my personal rel'ship w Dr Runacres...[he is] not a Doctor that you want to hand over what will be done & he will be receptive to it
#JusticeForVeronicaNelson

Describing Dr Runacres [Dr who did original med intake assessment of Veronica & who Registered Nurse Hills has testified overruled her when she said Veronica needed hospital], Ms Chisvo says: "Dismissive... Not wanting to hear what you have to say…"
#JusticeForVeronicaNelson

Ms Chisvo, prison Psychiatric Nurse, goes on to tell the Court that she then did handover notes and also did verbal handover with the nurse, and explained her recommendations
#JusticeForVeronicaNelson

Asked by Counsel Assisting about Dr Runacres' response, Ms Chisvo responds:
"I can’t recall his response, but he acknowledged what I said to him. I highlight what needs to be done and it’s up to the doc to take it up from there."
#JusticeForVeronicaNelson

On the relationship between Forensicare [her employer] and Correct Care (CC), Chisvo says, "We are like a stakeholder working in conjunction with CC, my job is to make rec; s of what needs to be followed up. I do this through the nurse in charge and I speak to the doc if needed."

The court is shown a form [DPFC reception psych nursing rec’s] with Chisvo's recommendation that Veronica be assessed again by a psych nurse the next day. This was handed over to the nighttime nurse, to give to the psych nurse the next day
#JusticeForVeronicaNelson

Ms Chisvo gives evidence that the next day she came in and was told by the Correct Care nurse that Veronica had been seen. She then said, "Until the day I learned that she had passed on there was no entry in Jcare to indicate she had been seen."
#JusticeForVeronicaNelson

Counsel: What might be the reasons a follow-up didn’t occur?
Chisvo: To be honest I do not know.
Counsel: Is this common?
Chisvo: It does happen sometimes, when you do follow-up and you’re just checking what happened.. It does.. and I do not know why things will happen that way

"I don't understand why she would say she had seen [Veronica] and yet she did not. Because what is not written down to me is not done, there’s no evidence. Ms Chisvo says she described this gap in the Forensicare incident report after Veronica's death
#JusticeForVeronicaNelson

On the reason she recommended a 2nd pysch asses. for Veronica the next day, Chisvo says, "I recommended to be seen the following day was because she was half awake half asleep & not in good state of mind for that conversation with her. Precautionary measure for another check-in.

Asked about the overlap between Forensicare and Correct Care (CCA) psych nurses, Ms Chisvo explains in the week Veronica entered prison, Forensicare were in the process of taking the 'at-risk,' inpatient and reception [psych asses.] role over from CCA
#JusticeForVeronicaNelson

Speaking of her notation on the document given to Corrections that rec'd Veronica stay in medical due to withdrawal symptoms, Chisvo says this info, "had to go to corrections ...because they're the custodians, they'rere the ones who needed to know in terms of the physical aspects

The Court hears evidence that before Forensicare took over it was practice that women were kept in medical overnight & Chisvo says this is why she recommended this for Veronica. Over time she learned Correct Care weren't meant to keep women in medical overnight but isn't sure why

Counsel: If you were aware that patients were not supposed to stay overnight in the medical centre, would you have alternatively wanted Veronica to be sent to hospital?
Ms Chisvo: Definitely yes
#JusticeForVeronicaNelson

"I’m not a medical nurse, not a medical doctor, but I definitely could tell that this woman was physically unwell. I would have assumed the doctor would just know…She needed further intervention that was not available within the prison service," said Ms Chisvo, Psych Nurse

Ms Chisvo cont.: "Just observing, [Veronica] was sick three times. When she laid back on her bed she had a [vomit] bag. Because she was constantly vomiting you would assume she needed some fluid replacement in her body. She looked pale, she looked unwell, you couldn’t miss it"

"I’m a psych. nurse, but I can tell when someone is unwell. Any normal person..can tell when someone is unwell. I would have thought the doctor would have taken it up and done what needed to be done because you could tell she was physically compromised"
#JusticeForVeronicaNelson

Miss Chisvo recaps handover she gave to the night nurse: "Ms Nelson is severely withdrawing, she is vomiting, she is unwell & needs monitoring.
I wouldn't have known what Dr [Runacres] would have recommended. Just saying from my perspective as a psych nurse from what I'd seen"

Asked if there were two types of observations, medical checks and welfare observations, Ms Chisvo agrees
#JusticeForVeronicaNelson

Counsel: What checks would you have expected overnight if Ms Nelson was being medically monitored?
Chisvo: Medical assessment to see if she needed further medical intervention which is provided outside of prison, actually in a hospital
#JusticeForVeronicaNelson

Ms Chisvo: "Because she was vomiting & not holding any food or anything ..[this] is part of my mental health assessment. She told me no [that she wasn’t eating or drinking], so I would have expected they would do a further assessment. Because there was a need for them to do that"

Counsel Assisting: In terms of that further assessment - Medical monitoring overnight, would you expect that would be done in person?
Ms Chisvo: Yes, definitely.
#JusticeForVeronicaNelson

CA: When providing med care to patients in a corrections setting..diff healthcare providers should be working as a team?
Chisvo: Definitely we should work as a team
CA: Part of working as a team is respecting each others' expertise, training & contribution?
Chisvo: Definitely

CA: You said in your evidence this morning that Dr. Sean {Runacres] can be dismissive
Chisvo: Yes
CA: Is that a common prob you experienced in Correction settings ... or specific problem with this doctor?
Chisvo: Not all Drs are like that, he had a diff approach & attitude.

Describing interactions with Dr Runacres at prison reception, Ms Chisvo said at times she would escort patients to med assessment, incl. if they felt unsafe to be examined by Dr alone. She gives an eg: "Before even explaining" why she had come, he said “you [the nurse] can leave”

"I don’t know whether it was like that with all the other clinicians, but my personal experience was, if you asked me I wouldn’t choose him [Dr Runacres] to be my doctor"
#JusticeForVeronicaNelson

Counsel Assisting: When a doctor is dismissive towards the contributions of a nurse regarding a patient, that creates a risk to patient safety doesn’t it
Ms Chisvo: Definitely
#JusticeForVeronicaNelson

Moving to protocols following a death in custody, Ms Chisvo says each organisation has its own policies and procedures, and with Forensicare for whom she worked, all staff who had "contact with the person who is now deceased within a certain period" must do an incident report

Counsel: Now corrections held a debrief on the 16/01/20, were you invited to that debrief?
Chisvo: No
Counsel: If you had been invited would you have gone?
Chisvo: Definitely
#JusticeForVeronicaNelson

Counsel: There was also a review into Veronica’s death completed by Justice Health, did anybody speak to you to contribute to that review?
Chisvo: No
Counsel: Are you aware if the incident report you completed was provided for consideration?
Chisvo: I’ve got no idea.

Counsel: I take it that if you had been asked to attend debrief or speak to people about review into the death in custody, you would have told them info consistent with what you put in incident report & statement & the evidence you’ve given to this court
Chisvo: Yes, definitely

Erin Gardner, Counsel for Correct Care begins questioning & challenges Ms Chisvo on whether she actually witnessed Veronica vomiting when that's not on CCTV of assessment in the cell. Chisvo explains she was standing by the door & gave Veronica time to finish before entering

Asked several times about this by Gardner, Ms Chisvo states, "I saw Ms Nelson vomiting."
#JusticeForVeronicaNelson

Asked if she new Veronica had already been seen by the Doctor [Runacres] before her assessment, Ms Chisvo responds, "Whether she had been seen by the doc, and prescribed med.i. It is still my duty of care to ensure she is prescribed medication & to communicate w doctor and nurse"

Asked again about her knowledge of prior medical assessment of Veronica and medication that had been prescribed but not administered, Ms Chisvo says, "My assessment is based on what is before me and what is required to be done."
#JusticeForVeronicaNelson

[1 of 2] Gardner: Would you agree that the nature of your assessment is primarily to assess psychiatric and psych issues prisoner may have?
Chisvo: No -my scope of reception assessment is to determine any emerging psych health, not only related to withdrawing. ..

[2 of 2] "If a woman is telling me her concerns about health, it is my job to escalate it to the appropriate person… the reason she needed to remain in medical is because of how she was presenting physically"
#JusticeForVeronicaNelson

Counsel for Correct Care: The handover to nurse is not reflected in JCare notes, is it?
Chisvo: I verbalised that and I indicated it… for Correct Care I indicated what needed to be done.. From me to them this was my rec.. my concern was her physical health

Asked again about her JCare notes, Chisvo reiterated that she verbalised her rec's [that Veronica remain in medical and be psych assessed again the next day] to the Correct Care nurse and indicated them on the form to Corrections
#JusticeForVeronicaNelson

"For Correct Care, I indicated what needed to be done, which they are implying had already been done by the doctor. I am repeating myself that I understood that Corrections Victoria would determine the placement."
#JusticeForVeronicaNelson

"I had no concerns with suicidal or self-harming issues, but my concern was she [Veronica] was physically /medically unwell and might need to be monitored for medical purposes" - Bester Chisvo, Psychiatric Nurse
#JusticeForVeronicaNelson

Gardner, Counsel for Correct Care, again questions Ms Chisvo on her memory of seeing Veronica vomit. Ms Chisvo responds, "I walked in when she was covering the vomit on the floor. We waited for her when she was being sick & vomiting before walking into the cell. She covered that"

Gardner: Just that you haven’t recorded in statement or notes the number of times she vomited or that she vomited in front of you.
Chisvo: I actually saw her vomiting and that’s before I entered that cell
#JusticeForVeronicaNelson

Gardner concludes and Sophie Pennington, Counsel for Forensicare commences her questions of the witness
#JusticeForVeronicaNelson

Pennington goes through notes from Chisvo made 3 mins prior to CCTV in the cell that state, “Had to be reviewed in holding cell as actively vomiting.” She notes that Ms Chisvo's evidence is consistent with, "Standing outside the cell a few minutes before you entered"

Ms Pennington puts to Ms Chisbo that the handover printout and referral material she wrote, "Maintains your view at that time that at 5.45pm she was very unwell and needed some further review". Ms Chisbo responds, "Correct".
#JusticeForVeronicaNelson

Mietta McDonald, Counsel Assisting asks why Ms Chisvo didn't complete the follow-up psych review herself, and Ms Chisvo explains that her role with Forensicare was reception psych assessment, and follow-up assessments are done by Correct Care
#JusticeForVeronicaNelson

"My role is to do an initial psych assessment. And because we have Correct Care...another service provider they then follow up, hence there was a reception follow-up assessment that can be done in a week’s time or a month depending on the level of mental illness presenting...

"For [Veronica] I ... wanted another welfare check because of how she was under the influence and I wasn't 100%. I just wanted to be thorough with the mental health aspect," said Ms Chisvo.

Ms Chisvo's evidence concluded and the witness is excused.
#JusticeForVeronicaNelson

Court breaks for lunch and then Mark Minett, Registered Nurse, Correct Care Australasia takes the stand. He makes an amendment to his written statement where he says Veronica's vital signs were 'unremarkable', as he has since learned that her heart rate was above normal expected.

Counsel Assist. goes over evidence of Veronica arriving at DPFC prison 31/12/19 with a vomit bag, having vomited in transit. She confirms Minett was working that day & that on this shift he was not the nurse who assisted the GP w assessments, but had other med centre duties

Minett gives evidence that on 31/12/19 he did not know Veronica was being held in the medical centre ward, or that there was a patient who was vomiting in there. He was on other duties and was running a clinic in the prison.
#JusticeForVeronicaNelson

Minett testifies that the first he learned of Veronica's being in the prison was when he received handover from a nurse when he arrived at work the next day (1/1/20). He said this was brief verbal handover, "That a person was being held overnight who was reportedly withdrawing"

On this shift, 1/1/20, Minett's role was that of GP nurse, and his job was to assist the medical officer in their receptions and medical assessments
#JusticeForVeronicaNelson

Minett testifies he was told Veronica had been 'recepted' at the prison as new inmate and had undergone a med assess by psych officer & med nurse the day before. "I was also told that she was withdrawing heavily from opioid use and had been unwell overnight including vomiting”

As Veronica had already undergone prison reception medical assessment with Dr Sean Runacres, Minett's role was to assist the GP on Shift - Dr Brown - with a review. He was meeting Dr Brown for the first time, as it was her first shift at DPFC
#JusticeForVeronicaNelson

CA asks Minett about prison reception medical assessments, and how these should run [the Court has earlier heard evidence from Nurse Hills, who was at Veronica's reception medical assessment that the assessment by Dr Runacres was not adequate]
#JusticeForVeronicaNelson

CA: They’re [recpetion assessments] understood to be comprehensive med assessments is that right?
Minett: Yes
CA: They’re expected to be a fulsome enquiry into the health of a new prisoner that’s arriving?
Minett: Comprehensive, yes

Mr Minett confirms that at this prison medical assessments, the doctor leads the assessment and records the details, and the nurse assists the GP
#JusticeForVeronicaNelson

Asked what triggered he and Dr Brown to see Veronica for a medical review that day, Minett responds, "The main trigger would have been the handover to say that Veronica had been in overnight, and was unwell due to withdrawing"
#JusticeForVeronicaNelson

Counsel: Were you given any more information about Veronica’s condition, once you returned from your med rounds?
Minett: No additional info, no
Counsel: Were you told how many times during the night she’d asked for a drink?
Minett: No
#JusticeForVeronicaNelson

CA: Were you told she’d reported cramping?
Minett: Not until we actually did the assessment, nothing prior...
CA: You weren’t told anything else by nursing staff?
Minett: No
CA: Were you told that she had asked 4 or 5 times to see a dr during the morning?
Minett: [shakes head]

Counsel: So in terms of you taking you and Dr brown attending in there, it was simply triggered by the info she’d been vomiting?
Minett: And that she needed a review because she had spent the night unwell
#JusticeForVeronicaNelson

Moving to why the medical review of Veronica was done in the cell:
Counsel: Can you say why it was that it was done in the cell?
Minett: My understanding is it was better for us to go to cell as she was feeling unwell
[1 of 2]

Counsel: Did you have info about that?
Minett: Not really… it was as we went over earlier I was informed she [Veronica] was unwell and we could see her in the cell.. that it would be kinder for her
#JusticeForVeronicaNelson

Moving to description of the cells in the prison medical unit, Minett agrees that the doors are very similar to cell doors in the rest of the prison - locked doors, with a trap, locked, and the main diff is a glass window at the top and glass window on the side wall for ob's.

Minett gives evidence that confirms that the only communications available to prisoners in cells in medical ward is via a buzzer, and that buzzer goes to Corrections staff, not health staff. So if a person/patient buzzes, it is a CO who answers
#JusticeForVeronicaNelson

About the post where the buzzer is answered, Minett says this is a shared open space with nursing post. He agrees if patient buzzed from ward cell, the CO could call out to a nurse, but this didn't generally happen, "because we dont really hold that many unwell patients in there"

Counsel: Are there not often people being held in those ward cells [medical unit]?
Minett: Not often
Counsel: So prisoners are taken into treating room to see doctor and mental health nurses, but rarely held?
Minett: Rarely
#JusticeForVeronicaNelson

Asked about the medical examination he and Dr Brown did of Veronica, and whether her [higher than normal] heart rate of 123 should have caused concern, Minett says, "It’s something that should be considered for sure"
#JusticeForVeronicaNelson

Minett testifies that Veronica told he and Dr Brown she had been vomiting and had diarrhea overnight, and says that he noticed her low weight. He describes encouraging her to drink fluid with electrolytes [shown in CCTV viewed earlier by the court]
#JusticeForVeronicaNelson

Minett describes the usual practice of Doctors entering notes into JCare [electronic file notes] after a medical assessment, and explains that Dr Brown did this after seeing Veronica
#JusticeForVeronicaNelson

Several times over the course of the inquest, the court has heard evidence that the JCare record from Veronica's first prison reception medical assessment by Dr Runacres [the day before she was seen by Minett and Dr Brown] contained a no. of errors, including incorrect bodyweight

Minett is asked about the importance of JCare notes:

Counsel: And is it a source of info that you would expect could be relied upon?
Minett: Yes
Counsel: You’d expect it to be accurate?
Minett: You would think so, yes
#JusticeForVeronicaNelson

Asked if medical staff might rely on notes in JCare when making decisions about treating a patient, Minett responds, "If additional info was required, it could be relied on."
#JusticeForVeronicaNelson

Counsel Assisting moves to asking about the notes from Minett & Dr Brown's medical review of Veronica, where it is noted that she was "alert and orientated". Asked about this, Minnet says, "I don’t think she was 100%"
#JusticeForVeronicaNelson

CA: If she was 100% you wouldn’t need to have given her an injection in her bottom to try and stop her vomiting..?
M: Well, we gave the injection to stop the vomiting, yeah. Or the nausea.
CA: And the vomiting, in itself is...reflective of her being unwell, isn’t it?
M: Yes.

Minnet has given evidence that he saw Veronica in the morning, but did not see her again after lunch, as he was on the understanding that she was being moved back into Yarra unit [out of medical unit]
#JusticeForVeronicaNelson

CA: Do you see the line [in the notes from Veronica's morning med review that] that says ‘review with nurse and obs this arvo’
M: I see that
CA: Did Dr. Brown discuss with you the need for nursing observations to take place in the afternoon
M: I do not recall her saying that

CA: Would it be the usual practice that the Dr would say to you, verbally, a direction, if they required something of you after the review?
M: If there was a plan, it would be reasonable to expect they would tell the nurse yeah
#JusticeForVeronicaNelson

CA: And you accept as we understand it, that there was a plan that required you to review V in the afternoon?
M: I accept that there was a plan
CA: And do you accept that a part of that plan was that you conduct nursing observations upon her in the afternoon?
M: I accept that

CA: Do you accept that that should have occurred by you?
M: Yes, I accept that
CA: Do you also accept that by that review & those observations not occurring, that was a missed opp to assess Veronica for signs of deterioration?
M: It was a missed opportunity to review her yes.

Counsel Assisting: And that, had she been reviewed at that point, the course for her, from there on, could have been different?
Minett: It may have assisted Dr brown in her determination
#JusticeForVeronicaNelson

CA: If those observations had shown a deterioration in Veronica’s health, what could Dr Brown have done with that information. She could have sent her to hospital, couldn’t she?
Minett: That’s a possibility

CA: You could've sent her to hosp.. if the ob's had revealed sig. deterioration
M: If I was that alarmed I would've made the call, yes
CA: But you say you... weren’t suff. alarmed to send her to hospital?
M: I didn’t do further review so didn’t have the opp to be alarmed further

What we know from the video footage is that after that first review that takes place in the morning at about 10.30am, Veronica vomits at 11.12am, and then again at 11.37am, and then again at 12.21pm, and then it’s about 12.30pm when Minett & Dr Brown went in and saw her again.

At this 12.30pm medical review, no nursing observations were taken.
Counsel: So the last nursing obvs you have on her are about 10.30 in the morning
Minett: Yes
#JusticeForVeronicaNelson

CA: Now what we know is that after that second time when you attend with Dr. Brown, Veronica vomits again at 1.11pm, and again at 1.34pm, she vomits again, was that information that you were aware of?
Minett: No, not at all

Asked how that info about frequent and voluminous vomiting would be passed on to nursing or medical staff, Minett responds, "I believe that we would rely on the custodial [Corrections] staff to inform us"
#JusticeForVeronicaNelson

When asked if it would be important to collate information about frequent vomiting, to inform med. staff knowledge of a person’s health, and their degree of wellness or otherwise, Minett says, "It would be valuable information, yes."
#JusticeForVeronicaNelson

Re-visiting the issue of the buzzer in cells in the med unit being connected to Corrections Officers, Minett agrees that it would probably be more helpful to providing nursing staff more information about the deterioration of patients if they were connected to nurses instead

CA: If those buzzers were answered by medical staff... do you think that the nursing staff might have more information..about the deterioration of a patient.
M: Are you suggesting that the intercom could be connected to the nurses' station?
CA: Yes
M: That would probably help.

CA:.. [If] a patient in the med centre cell was buzzing to say they had vomited, the medical staff would then know that information, wouldn’t they? Is that something you think might be useful?
M: Can’t hurt. Any information would add to the benefit of patients if they are unwell

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