Thread by @dhadjowa

Day 18 of the coronial inquest into the death in custody of Veronica Nelson. The medical panel of experts will begin their evidence. Head down to the Coroner's Court, listen in using the below link, or follow here for updates
#JusticeForVeronicaNelson
csvic.webex.com/mw3300/mywebex…

Today is referred to as a ‘Medical Hot Tub’. It involves concurrent evidence from 2 panels.
1. A Med Expert Conclave, made up of a group of subject matter experts
2. A Med Stakeholder Panel w Senior Reps from Justice Health, Correct Care & The Victorian Aboriginal Health Service

The presence of the Med Stakeholder Panel is to provide their opinions around current policy and procedures & to provide feedback on the practical recommendations, prevention and systems improvement opportunities put forward by the Med Expert Conclave

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The 2 panels are sworn in. Counsel Assisting begins by presenting a series of statements to the Med Expert Conclave. They are asked to agree, disagree or provide clarification to these statements. Other Counsels are then invited to ask qs based on their answers.

The first question from Counsel Assisting takes the med expert panel through their position on key definitions, for cultural competence, cultural safety, and stigma. The panel gives consensus responses to each of these definitions

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CA: Was Veronica's med assessment, treatment or care between 31 Dec 2019-2 Jan 2020, reasonable and appropriate?

Med Expert Conclave: There are some dissenters on the specifics of how care might have been improved but general consensus is that [care] could have been improved

CA asks about the majority view of the care provided by Registered Nurse Hills. RN Hills was present in Veronica’s initial med intake, and gave evidence she suggested Veronica be transferred to hospital but was overruled by Dr Runacres

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Conclave of opinion that Hills’ assessment was reasonable, but management was not.

Med Expert Panel acknowledges Hills made an attempt to escalate Veronica's care, however “given the discrepancy of opinion with Dr Runacres, that placed an onus on Ms Hills to escalate her care"

Med Expert Panel of the view that in a well-functioning healthcare team, hierarchies shouldn’t be too rigid, but should instead allow for collaboration and resolution of concerns if dissenting views exist - including between the nurse and doctor on a treatment team

In speculating on options for escalation (incl by a nurse) in the prison med context, the panel gives the caveat they, “weren’t really aware of what the escalation options were, we are just of the view they do exist in some form & should have been used”

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CA asks about the majority view of the conclave in relation to if the medical care provided by Dr Runacres was reasonable and appropriate. Dr Runacres conducted Veronica's reception medical intake assessment when she arrived at DPFC on the evening on Dec 31 2019.

Med Conclave: Some of the medical panel concluded that the assessment conducted by Dr Runacres was adequate and some concluded that it was not. As a group however, we did have concerns regarding some of the content, or rather lack of content, in his assessment

Concerns raised by med conclave in relation to Dr Runacres assessment included: inaccurate notes and gaps in assessment, failure to record that Veronica was withdrawing from opioids, no cultural assessment, no inquiry of previous vomiting, or any formal assessment of hydration.

Med conclave comments on the disagreement between Hills & Runacres regarding escalation of Veronica's care.

They "were puzzled by the lack of any records" of the differing assessments & suggest that "this unresolved difference of opinion" impacted negatively on Veronica's care

Med Conclave comments on the absence of the development of a management plan for Veronica by Dr Runacres:

"There appears to have been a lack of a forward plan for management, which at least should have included better observations."

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The court hears that many members of the Med Expert Conclave conclude that Veronica's low weight and history of vomiting alone "should have been sufficient grounds [for Dr Runacres] to transfer her to the hospital" after her intake medical assessment.

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The Conclave gives evidence that there is some dissent with this conclusion, however this is provided with the following qualification:

"The majority would have escalated [Veronica’s care] when she walked in the door. All the dissenters would have escalated half an hour later"

Evidence from the Medical Conclave moves to questions in relation to the medical assessment, treatment and care of Veronica by Dr Alison Brown. Dr Brown was the doctor on duty at DPFC on 1st of Jan, 2020.

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The majority of the expert medical conclave concluded that Dr Brown’s assessment of Veronica was adequate, however there was one dissenting voice. This dissent, from Dr Megan Williams, was based on failure to complete a cultural assessment of Veronica at the time.

The panel states that in her assessment Dr Brown correctly identified deterioration, vomiting, and abnormal vital signs. Med Expert conclave note that when assessed on January 1, Veronica’s vital signs fell within Ambulance Victoria criteria for immediate transfer to hospital.

While the majority of the expert conclave concluded that Dr Brown’s assessment of Veronica was adequate, the conclave unanimously concluded that her medical treatment of Veronica was inadequate

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Expanding on the unanimous conclusion of the inadequacy of Dr Brown's treatment:

"The treatment was inadequate because there was no resulting change in [Veronica’s] care (despite evidence that her condition worsening)....the assessment was okay, but the action wasn’t.”

The Medical conclave commented on their conclusion of appropriate treatment for Veronica's when Dr Brown was her treating doctor at DPFC:

“We unanimously thought [Veronica] should have gone to hospital”

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The Med Conclave notes significant vomiting of a projectile nature & failures to adequately doc this:

“There should be clear doc of hydration status...also good doc of fluid intake… and fluid losses, as these were becoming very serious at this point in Veronica’s condition.”

The Med Conclave is asked about the increase in Veronica’s heart rate from 60BPM to 123BPM from Dr Runacres’ to Dr Brown’s med assessment. The Med Conclave concludes that Veronica’s increase in heart rate was part of the overall picture of her deterioration & dehydration

On Veronica’s heart rate on Jan 1 the day before she passed away, the medical conclave spokesperson states:

“[Veronica] was at a point now where her life was potentially at risk and it was not being addressed.”

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Asked about Veronica’s state of malnutrition, Dr Sally Bell, a member of the Medical Expert Conclave comments:

“Malnutrition is associated with worse outcomes across the board in all healthcare settings”

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Asked by Counsel for Aunty Donna (Veronica's Mum) about the plan for oral hydration of Veronica at this point in time, Dr Diane Chambers GP responds:

“Treatment of dehydration should be based on initial assessment, which was not done.”

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Dr Chambers continues and states that oral rehydration is appropriate with mild levels of dehydration, but notes that it is not adequate with serve levels.

"Veronica needed to have an assessment of electrolytes to determine if oral was appropriate or IV required.”

Dr Nico Clark, member of medical expert conclave continues: We [medical conclave] all felt that [Veronica] should go to hospital.

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Dr Clark continues: If you make a plan for oral rehydration..it’s contingent on [monitoring how this is absorbed]...Veronica vomit[ed] consistently 5-10 mins after she has a glass of water… it wouldn’t have been difficult for staff to tell oral rehydration wasn’t going to work

Commenting on CCTV of limited attempts to offer oral rehydration & Veronica's cont vomiting, Dr Sally Bell states:

It was clear that she had inadequate oral intake and a lot of output...she [needed] to go to hospital because she needed IV rehydration

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Asked by Counsel for Dr Brown which of Veronica’s symptoms overlapped with symptoms of opiate withdrawal, member of Med Expert Conclave Dr Clark states that Veronica’s high heart rate “would be very unusual for opiate withdrawal & would raise qs that something else was going on.”

Dr Clark goes on to state that Veronica’s “degree of vomiting wouldn’t be typical of opiate withdrawal”

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Dr Walby, Expert in Emergency Medicine, comments on ‘diagnosis momentum’ (when a previous diagnosis is accepted without sufficient scepticism) and notes:

“[Veronica] has been labelled as in ‘opiate withdrawal’...as time has gone by, that label has become ‘stickier and sticker."

Dr Walby notes that despite Veronica stating that she was going through heroin withdrawal, it was the responsibility of the medical practitioner to put that aside and make an objective assessment of Veronica

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Member of Expert Medical Conclave Professor Carla Treloar notes:

"This isn’t just a ‘sticky’ diagnosis . We know that women who use drugs are seen in a stigmatising light, and often claimed to be seen as 'drug seeking’ when trying to access relief for their [symptoms]."

Responding to a q from Mr Mukerjee, Counsel for Dr Brown, as to what was reassuring about Veronica’s condition, Dr Andrew Walby, Doctor of Emergency Medicine states:

“I find nothing reassuring about [Veronica's] condition from 11am on the 1st Jan. She needed to go to hospital”

Counsel for Dr Brown asks the conclave about Dr Brown retaking Veronica’s pulse.

Dr Clark comments that "it's hard to think of a pulse rate that would have reassured us that things would be okay" given Veronica's overall presentation

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Dr Rick Miller, GP, and member of Medical Conclave adds:

The only thing that would have reassured us would be that [Veronica] had stop[ped] vomiting and passed urine. Blood pressure had gone up, pulse had come down. She looked good and felt well.. The whole lot, not one thing.

CA asks the Medical Expert Conclave for their conclusion on whether the medical assessment, treatment, or care was reasonable and appropriate in relation to assessment, management and treatment by Registered Nurse Mark Minute

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A consensus view is provided by the Expert Medical Conclave that the care Veronica received from Registered Nurse Minute was inadequate. Mr Minute was working at DPFC on Jan 1 & has given evidence that he did not undertake a review of Veronica on the arvo of Jan 1.

Nurse Minute's care was deemed inadequate by Med Conclave because: pulse rate of 123 stated as 'unremarkable', no acknowledgement or documentation of multiple vomits, failure to ensure hydration & electrolytes that were given were tolerated, no monitoring of urine output

Further, there was consensus by the Med Expert Conclave that Nurse Minute's care of Veronica was inadequate because "the care was culturally unsafe. Veronica was distressed and alone.”

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CA asks Dr Jenny Hunt, Clinical Director of VAHS, if it would be possible to transport a holistic approach to heath into a carceral setting:

H: I think we could deliver care that would approach that. It would be very constrained by the environment ...but I think we could do it

CA asks the Medical Expert Conclave for their conclusion on whether the medical assessment, treatment, or care was reasonable and appropriate in relation to assessment, management and treatment by Registered Nurse Athena George on Jan 2

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Nurse George was working the night shift at DPFC on Jan 2 and was the last medical practitioner to have contact with Veronica in the early hours of the morning on Jan 2.

The expert med conclave states they unanimously view Nurse George’s care of Veronica on Jan 2 as inadequate

Nurse George's care was deemed inadequate by Med Expert Conclave due to: failure to observe and assess Veronica when administering Panadol, requests for help were ignored & failure to escalate Veronica's care and call an ambulance

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CA asks Med Conclave what sort of medical assessment Nurse George would have been able to conduct through a closed door.

Tracie Ham, Registered Nurse respond on behalf of the conclave:

"Very little. The door would need to be opened."

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CA asks RN Tracie Ham about Nurse George's responsibility to have the door opened to conduct an assessment of Veronica.

RN Ham: If I was in that position I would demand to have the door opened. I would make phone calls to make it happen. Somehow, I would make it happen.

The Med Expert Conclave is asked how urgent hospital care for Veronica would have been if her BMI was closer to 13 rather than the BMI of 15 recorded in Dr Runacres' intake assessment:

"Everyone is of the view that with a BMI of 13 she should have been transferred to hospital"

Dr Yvonnne Bonomo, comments on the focus on numbers (such as BMI, heart rate, blood pressure):

"...It's not about the numbers...It's about understanding where Veronica is at when she comes into that prison."

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Dr Bonomo comments on the level of care Veronica received, noting that it should have been trauma informed:

"Making [Veronica] clean up her own vomit while the nurse is making an assessment of her mental state, it defies any humane interaction."

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Dr Bonomo continues:
"If the whole system worked as a team, then the health professionals as well as the prison officers, if they had been communicating with each other, [Veronica's] deterioration would have become very apparent & the need to act would have become very apparent"

Referring back to focus on numbers, Dr Bonomo states:

"I find it quite disturbing & distressing that we seem to be trying to focus on numbers, rather than the overall picture, which is so clear, that needed to be acted upon. Anyone could have helped that process of escalation."

Counsel Assisting asks the Med Expert Conclave if Veronica's medical assessment, treatment or care was reasonable and appropriate in relation to alternative causes for her symptoms and whether they'd been considered.

Dr Clark comments on behalf of med conclave that the extent & volume of Veronica’s vomiting "should have warranted a consideration of the cause of her vomiting beyond uncomplicated opiate withdrawal…When the taken into consideration, we would have transferred her to hospital"

Dr Clark comments on behalf of med conclave on Veronica's pulse of 123BPM on morning of Jan 1:

"This is really a key sign of clinical deterioration and should have triggered escalation of Veronica's care"

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Dr Clark comments on behalf of med conclave that Veronica's frequent complaints of abdominal pain, vomiting and severe cramps should have resulted in an escalation of Veronica's care.

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Dr Clark comments on behalf of med conclave about Veronica's hand cramping on early hours of Jan 2:

"Cramps of this nature are a clear indication of significant electrolyte disturbance."

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Dr Clark comments on behalf of med conclave about lack of assessment of Veronica's level of dehydration:

"If there had been a more sophisticated analysis of her dehydration, this could have been an opportunity for escalating [Veronica's] care.

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CA: At what point should [Veronica's] care have been escalated?

Dr Clark on behalf of conclave: At all of those points, plus in addition to the med reception assessment... Some of us felt like she should go to hospital at this point, and some of us didn't.

Dr Bell speaks to the absence of other care for Veronica:

“Not just medical care, personal care. She was not offered any explanation of what was going on. She was not offered any support. She was never asked whether she wanted to contact or speak to anybody.”

Member of Med Conclave: We're talking about very basic medical signs: dehydration, vomiting, malnourishment. It's a recipe for absolute disaster in any context. The opportunity was lost at that time by not transferring [Veronica] to hospital given the very basic medical signs

Dr Sally Bell:

"Many of us were deeply concerned that [Veronica's] human had been breached. The way she died was alone & without dignity. It was unnecessary. I think all of the people involved need to reflect on that, not just if one individual was more at fault than another."

Professor Megan Williams speaks to the absence of any Aboriginal Health Practitioners at DPFC. She notes if present, they could have responded to the diff dimensions of Veronica’s health as an Aboriginal woman, from the initial medical reception intake at DPFC prison

Dr Carla Treloar comments on “the numbers of people [including Corrections Officers who took Veronica’s intercom calls] who were involved in providing non-qualified medical advice to Veronica to drink water to take salt, etc..”

Dr Treloar cont: "I draw a larger pic here about the stigma endured by people who inject drugs & particularly women who inject drugs & point to the role of that in de-escalating and delegitimising Veronica's experiences as an extremely unwell person...receiving inadequate care.”

The Med Conclave is asked about Correct Care's revised guidelines around heart rate for calling an ambulance. We hear that a rate below 40 or above 130 would require calling an ambulance & below 50 or above 120 requires a med review within 30 mins, or ambulance if review not poss

Dr Clark of Med Conclave responds that revised guidelines seem appropriate and are in line with Ambulance Victoria clinical practice guidelines around heart rate in relation to assessment triage of the patient's clinical condition

Dr Bonomo, Addiction Physician, adds:

“It's the clinical picture…numbers are a guide. You have a woman with a very low BMI..who's projectile vomiting, who's becoming more and more distressed... She's lying in her own vomit. The clinical picture is screaming deterioration.”

Dr Bonomo cont:

“While on paper, pulse rates are helpful guides, it's the overall clinical picture that speaks volumes...If we keep focusing on 'what number does one seek to escalate care' we're missing the point completely."

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Ms Davidson, Counsel for Victorian Equal Opportunity & Human Rights Commission (VEOHRC) asks the Med Expert Conclave a number of qs about the treatment options that would have been available to Veronica in the community comparatively to that offered in DPFC.

Dr Nico Clark of Med Conclave gives evidence that if Veronica was in the community and chose to stop using heroin should would have had access to opioid substitution therapy (Methadone, Suboxone, or the long acting injectable formulation).

Q: The other alternatives [Veronica] might have had was rapid withdrawal with Suboxone, is that correct?

Dr Clark of Med Conclave: That's one way of withdrawing... I would have discouraged her from withdrawing in this context.

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Counsel asks about the amount of Suboxone provided for rapid opioid withdrawal in the community.

Dr Clark: You would tailor the dose to the specifics of the situation, depending on their tolerance for withdrawal both physically & mentally.

Counsel for VEOHRC asks about the consequences of the limited treatment options for women on remand withdrawing from opioids, who are effectively forced to detox in prison

Dr Clark gives evidence that "there are multiple negative consequences": A greater severity of discomfort, potential for opiate withdrawal to lead to health problems, overdose risk if they recommence opioids, while on remand they may be tempted to use opioids in unsafe ways

Dr Bonomo states: "we can expect that [Veronica] would have gone into a moderate to severe withdrawal... That could have been anticipated and should have been treated. To not treat it was inhumane."

The Med Conclave unanimously agree with the description of treatment as inhumane

Q: Can the addiction medicine specialists speak to whether it would be possible to provide [opioid] substitution therapy on the first day in custody?

Dr Clark: Certainly from a medical perspective that that would be preferable.

Dr Clark comments on the policy around 6 weeks of uninterrupted time in custody in order to get access to opioid replacement therapy:

"That makes no sense to me whatsoever."

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Dr Clark goes on to give evidence that the shorter the time the person is in custody, the more important it is to ensure that the individual has access to an uninterrupted supply of opioids, to prevent them from going into opioid withdrawal

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Andrew Woods, Counsel for Percy Lovett, Veronica's partner asks the Expert Medical Conclave if there was a consensus view amongst the Conclave as to whether or not Veronica was in pain, and if so substantial pain, when she passed away

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Dr Clark, on behalf of the Expert Medical Conclave:

"I believe that's there is a consensus from the panel here that [Veronica] was in substantial pain at the time of her death."

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CA asks Professor Williams about the cultural and/or psychological impacts of forced opiate withdrawal for Veronica in circumstances in which she is imprisoned by a colonial institution

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Prof Williams: You can hear in Veronica's voice sheer distress. We witness multiple points of continued disempowerment. Veronica’s...actively asked for help...She's asked for clarification. She's followed up. She's displayed a number of actions to try to help herself...

Prof Williams cont: It's extremely taboo, is one word. Difficult, inappropriate, damaging for an Aboriginal person to pass away in an institution, in a colonised setting, where Aboriginal people have very little power to shape that system to respond to our needs & cultures.

Prof Williams cont: For an Aboriginal person to die in pain…Sally Bell mentioned the psychological and the physical pain but the spiritual pain as well. The lack of freedom for Veronica’s spirit at that point in time.

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Prof Williams cont: There's multiple factors that signify that this was a profoundly damaging situation…Despite overarching policies that indicate that there's a commitment to [First Nations] health and cultures and that they will be respected.. That disconnect is profound..

Dr Vickers, Gastroenterologist, adds: "The way [Veronica] died was utterly appallingly, undignified. [Veronica] was left in a concrete cell without any of her own kind people and died in pain and suffering, and that is absolutely appalling"

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CA asks Med conclave for their expert opinion on factors that may have impacted upon Veronica's decision not to be moved to the Med Unit in DPFC in the early hours of January 2, 2020

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Med conclave give evidence that Veronica likely got the message that nothing was going to be done for her & that putting onus on Veronica to make a decision about the best course of healthcare in this moment was unprofessional and irresponsible given her condition

CA asks Med Expert Conclave if they believe Veronica's death was preventable & up to what point they believe this was the case.

There is a consensus that Veronica’s death was preventable and a consensus that Veronica needed to be transferred to hospital on morning of Jan 1.

Expert Med Conclave gives evidence that it is hard to make a call about when Veronica’s death was no longer preventable, but are of the view that Veronica's death may still have been preventable when she requested med assistance at around 1:30am on Jan 2.

Dr Bell adds:

"Once again, the court is seeking a time point...This is a continuum. Your chances of survival diminish as you get sicker...We do think there is a very high chance that she would have survived had she been transferred at approx 11am."

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Counsel for Fitzroy Legal Service asks Ms Fuller, Deputy CEO/Chief Nursing Officer at Correct Care if Correct Care requires any degree of Addiction Medicine training for health practitioners working within prisons

Fuller: We don't require it, but we we encourage it.

Counsel for Fitzroy Legal Service asks the Expert Med Conclave if they believe it is essential that health practitioners working in prison have some form of addiction medicine training

Dr Bonomo: "The requirement to have some specialisation in drug & alcohol should be mandated"

Court adjourns for the day. The Medical Hot Tub, made up of the Medical Stakeholder Panel and the Medical Evidence Conclave with resume their evidence tomorrow at 10am.

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