The New South Wales deputy state coroner has asked why hospital transfer medical records were incomplete for a First Nations man who died in custody.
An inquest is examining the care given to William Patrick Alwyn Haines, known as Bill, who suffered from a heart condition and died at the Cessnock Correctional Centre on April 27, 2021.
The family of the 37-year-old Bundjalung, Goomeroi man had wanted an inquest to determine what care he was receiving for his heart condition while in prison.
Outside Tamworth Local Court, Roy Haines spoke of his family's anguish over the death of his son Bill, who died alone in a single-person cell.
"It's hard to listen to it but we have to be here for Bill," Mr Haines said.
The inquest heard Bill was found unresponsive, just over two hours after a fellow inmate brought him breakfast and gave him a daily newspaper.
DVT alert lacking
An inquest into Mr Haines' death is being held in Tamworth by NSW Deputy State Coroner Carmel Forbes.
The inquest has heard that at the time of his death, Mr Haines had a history of asthma, dental issues, acute opioid dependence and carditis.
Counsel assisting the coroner, Michael Dalla-Pozza, told the inquest Mr Haines also had a history of deep vein thrombosis (DVT) dating back to an admission to Prince of Wales Hospital in June 2019.
Justice Health's clinical director of primary care, Dr Gary Nicholls, told the inquest that in June 2019 his organisation was moving records from paper form to electronic form.
That prompted questioning by Ms Forbes about why a DVT alert for the 2019 event was not entered anywhere in Mr Haines' file.
"Why was there no alert in 2019, that is when you would expect an alert to go on the file," Ms Forbes said.
Dr Nicholls responded by saying that: "Justice Health's electronic system was in the early stages of being used … I agree that [alert] was an omission."
DVT risk not in notes
The lack of a DVT alert and incomplete notes about Mr Haines' health history were the focus of questioning about an admission to Cessnock Hospital on March 9, 2021, after he was taken there from the Cessnock Correctional Centre.
Mr Dalla-Pozza outlined a chain of events in which Mr Haines was transferred to several hospitals over the following days.
"Treatment received at Cessnock Hospital was appropriate but a history of left leg DVT was not obtained," he said.
"Upon transfer to Maitland Hospital [the next day] no venous thrombosis was documented."
Mr Dalla-Pozza said that Mr Haines was then transferred to the John Hunter Hospital, however no venous thrombosis risk assessment was done because his history of DVT had not been included in his medical file.
He was subsequently returned to Cessnock Correctional Centre, where he later died.
Dr Nicholls conceded Mr Haines' medical notes provided by Justice Health to Cessnock Hospital were lacking.
"The history of left leg DVT was not provided to Cessnock Hospital, I accept that," Dr Nicholls said.
Ms Forbes asked why transfer records prepared by a Justice Health nurse were incomplete.
"In an ideal world it would have been very helpful for the doctors to know about that DVT in 2019," she said.
"He'd been on blood thinners for three months for DVT in the recent past … why couldn't she [the nurse] have included that in her transfer document in this case?"
Dr Nicholls agreed that "an additional statement around the previous DVTs would have been additionally helpful".
Bill Haines' cause of death was determined to be pulmonary carditis.
At the end of his evidence, Dr Nicholls offered his and Justice Health's condolences to Mr Haines' family.
The inquest continues.
