A nurse told a coroner’s inquest she suggested sending Veronica Nelson to hospital the day she arrived in jail, but was overruled by a doctor who said the 37-year-old had the looking “generally well”, two days before dying alone in a cell.
Veronica Nelson’s family granted permission to use her image and requested that she be referred to as Veronica as a second reference.
- Nurse Stephanie Hills recalled the doctor telling her “you’re just a nurse”, who didn’t believe Veronica needed to be sent to the hospital at the time.
- She said she “deeply” regretted not arranging an ambulance for Veronica later
- Doctor Sean Runacres is due to testify at the inquest this week
Veronica was found dead at the Dame Phyllis Frost Center in Melbourne’s west in the early hours of January 2, 2020, after making multiple intercom calls for help.
An autopsy revealed she died of complications from a rare disease affecting the gut and heroin withdrawal.
Registered nurse Stephanie Hills told the inquest on Monday that she was “alarmed” by the appearance of female Gunditjmara, Dja Dja Wurrung, Wiradjuri and Yorta Yorta when she arrived at the remand prison on New Year’s Eve in 2019.
Ms Hills broke down in tears before telling the coroner she had to physically support Veronica as she had her blood pressure taken during her first checkup because Veronica was unable to support herself in the chair.
The registered nurse said that after observing Veronica’s low heart rate and low blood pressure, she told the doctor, Sean Runacres, who was carrying out the examination, that she was of the opinion that the sick woman should be sent to the hospital.
“I expressed my concern and said ‘do you think we need to send him to the hospital,'” Ms Hills said.
She said he responded by saying “I’m the doctor, I’ll make the decisions”.
“And I believe there was also a ‘you’re just a nurse,'” Ms Hills said.
She said that due to the medical hierarchy, there was “no way” a nurse with a doctor before them could overrule that decision and call an ambulance from the exam room.
“I had concerns, but ultimately it’s the doctor’s decision, what he does and what he doesn’t do,” Ms Hills said.
The nurse told coroner Simon McGregor that some of the observations recorded by Dr Runacres during the check-up were not taken during the examination she attended.
She said that was partly because it was not possible to put Veronica on the scale to be weighed or on an examination bed for a proper abdominal assessment.
The court heard that the questioning lasted about 13 minutes, which is 15 to 30 minutes less than it would normally take for an assessment of this kind.
Ms Hills said she felt at the time that the health assessment was not adequate and that a proper test of Veronica’s state of consciousness had not been carried out to justify Veronica’s normal score. Glasgow Coma Scale noted on health records.
“He [Dr Runacres] didn’t move from his chair nor did he examine his pupils to see if they were dilated, reaction, whatever,” Ms Hills said.
She said Veronica was “often inconsistent”, had trouble understanding the health documents she signed and repeatedly told healthcare workers “I feel sick, I’m in pain”.
In her notes, Dr. Runacres noted that Veronica “looked generally fine”, was “alert but not drowsy”, and “didn’t appear toxic”.
Ms Hills told the court she ‘absolutely’ disagreed that Veronica looked fine.
“She wasn’t alert, she was drowsy, she was slumped over the side of the chair like I said before, I have no idea what ‘appearance non-toxic’ is, I don’t never, ever read that in a medical record,” she said.
Dr Runacres, who was due to finish her work when Veronica was examined, prescribed her what is called a rapid withdrawal pack – containing opioids, anti-nausea medication and paracetamol.
Ms Hills said that after Dr Runacres left she reversed her decision to clear Veronica and send her from the medical unit to the general part of the prison.
Instead, she arranged to stay in the medical unit overnight for further observation.
She said she did so after seeing a psychiatric nurse whose note from Veronica’s first day in prison recommended that she remain in the medical unit ‘due to severe heroin withdrawal symptoms’ .
In her submission to the inquiry, Ms Hills said she “deeply regrets[ted]”not calling an ambulance and arranging for Veronica to be sent to the hospital that night.
Dr Runacres is expected to testify before the coroner later this week.
A veteran prison officer had never seen anyone as ‘skinny and frail’ as Veronica
Earlier, the inquest heard that a senior prison officer was “quite shocked” by Veronica’s appearance upon arrival at the Dame Phyllis Frost Centre.
Christine Fenech told the inquest she had never seen anyone look as “thin and frail” as Veronica when she arrived on December 31, 2019.
Ms Fenech said she spoke to her supervisor to express her concerns about Veronica’s health, but as she was not a medical expert it was not her role to send her to the hospital. hospital.
She also said Veronica seemed to “straighten up” at times and was able to wheel a trolley containing her belongings to a cell in the main part of the prison after leaving the medical unit on January 1.
Ms Fenech also told the inquest that when the prison was closed overnight, guards would need a security adviser to walk through and unlock the cells.
The inquest heard this meant that in the middle of the night if anyone needed a drink other than through their cell tap if they had a cup there was no way to provide this glass without contacting the supervisor.
As the hearings began, the inquest heard several distressing intercom calls Veronica made in the two days before her death, asking for cordial and something to drink as repeated vomiting left her severely dehydrated.
On several occasions, he was told that it was not possible because there were not enough officers on duty.
The inquest also heard a pink sign on Veronica’s door that said “new front desk: do not unlock” was routinely put on the door for newcomers to the Yarra main unit if they had not yet had a briefing on the rules.
“Just so they can have their first interview with staff members in the morning to go through all the orientation rules and unit regulations,” Ms. Fenech said.
Ms Fenech, who did not work in the Yarra unit where Veronica died, told the inquest she would ‘always’ go down to a cell if a prisoner used the intercom to call for help, so that she can see them “face to face” and better judge their well-being.