NSW coroner recommends review of medical staff conduct after prisoner's death

A NSW coroner has recommended medical staff who failed to treat, transfer or monitor a newly arrested prisoner for alcohol withdrawal should have their conduct reviewed by professional councils.

Dictor Dongrin and his brother were arrested in June 2022 after a violent and drunken incident at the family home in Coffs Harbour, in which their father Moses Dongrin was allegedly assaulted.

A coronial inquest heard the 29-year-old entered the Clarence Correctional Centre the day after his arrest, and by 2:29pm the following afternoon he was dead in a prison medical unit cell.

The court heard no physical medical observations were made during the previous 21 hours.

Deputy State Coroner Rebecca Hosking found Mr Dongrin died "from cardiac arhythmia in a state of alcohol withdrawal … and that timely and adequate medical intervention could have prevented death".

"Despite a score of eight [on a drug and alcohol scale] there was no appropriate consideration made to transfer Mr Dongrin to hospital."

Judge Hosking said the absence of any clinical observations following the initial intake assessment until the time of Mr Dongrin's death made his treatment "wholly inadequate" and it was likely he had been dead for up to 2 hours before resuscitation was attempted.

"Timely and adequate management could have prevented his death," she said.

Coroner's recommendations

Judge Hosking recommended the conduct of two nurses working at the jail be reviewed by the Nursing and Midwifery Council, and the actions of the specialist doctor overseeing drug and alcohol treatment at the facility be referred to the Medical Council of NSW for review.

Barrister Ian Fraser, who represented Mr Dongrin's family, told the inquest: "The cruel irony is Dictor Dongrin died in a clinical observation cell where no clinical observations were taken."

Mr Fraser attributed the failures to prison medical staff "working in a system of apathy which created a lack of responsibility".

The Clarence Correctional Centre is Australia's largest prison, housing up to 1,700 inmates, and is operated by global conglomerate Serco.

Legal counsel for Serco, Jilllian Caldwell, expressed the company's "sincere condolences" to the Dongrin family during closing submissions.

"Serco has already introduced a comprehensive range of measures in response to Dictor's death and we are committed to reviewing the coroner's findings to ensure we address any learnings from this inquest," she said.

Ms Caldwell said changes introduced since 2022 included structured medical shift handovers, daily briefings between prison health professionals, daily ward rounds, upgraded cell technology and staff drug-and-alcohol-awareness training.

Judge Hosking instructed Serco to conduct an audit of medical staff knowledge and familiarity with state health guidelines on drug and alcohol treatment, as well as reviewing policies on clinical observations and when to transfer patients to hospital.

She recommended corrections staff have access to the NSW Health single digital patient record, and to be able to enter observations to the record.

A 'broken' family

Mr Dongrin's mother Rebecca Deng spoke to the ABC after the coroner's findings were handed down.

"I'm feeling bad because people in the jail not do their job properly and not look after my son properly," she said.

Ms Deng said in Sudan, a person admitted to jail who failed a medical check would be sent to hospital.

"If good, if you are talking normal, OK, you can put in jail, but if no good, you take him to hospital," she said.

Ms Deng said she was "happy" with the changes made by Serco in the wake of her son's death.