A Perth woman who died in custody after being arrested over unpaid fines may have been deprived of "an opportunity to survive" because of delays in responding to a call that she was having a seizure, an inquest has been told.
Cally Graham was 31 when she died on February 26, 2017 after after she was jailed at Melaleuca Remand and Reintegration Facility for failing to pay fines.
It has taken five years for an inquest into her death, which her sister, Karis Graham, told ABC Radio Perth was "too long".
"It's been a long wait and a lot of emotions and a lot of heartbreak … and, unfortunately, my Dad didn't survive the wait for the inquest."
State Coroner Ros Fogliani gave her condolences to Ms Graham's family, who attended the first day of the inquest at Perth Magistrates Court on Monday.
Witnesses began piecing together a timeline of the days leading up to her death, including the failure to provide her with her epilepsy medication as well as a delay in giving Ms Graham oxygen as she was having a seizure.
Timeline of events emerges
Ms Graham was arrested over a series of unpaid fines on February 19, 2017 — the biggest of which was believed to have been just over $700 — and taken to the Perth Watch House in Northbridge, where a nurse notice she appeared "drowsy".
After telling the nurse she was epileptic, she was transferred to Royal Perth Hospital and prescribed the epilepsy medication Lyrica.
Back at the Watch House, her medication was sealed and labelled, but it was not recorded on the property receipt "for reasons which are not clear".
Ms Graham was then transported to the Melaleuca facility where she told prison staff she had been to hospital to get epilepsy medication, was withdrawing from heroin and felt sick.
Registered nurse Ann-Marie Brennan conducted a health assessment but said Ms Graham had not mentioned a history of epilepsy or the medication.
Property records showed the Lyrica dispensed to Ms Graham in hospital was received and documented by the facility, but the Department's Death in Custody Report suggested this was done the next day, after Ms Graham had already left.
Ms Brennan said her observations, including pulse and blood pressure, were stable and she was "quite chatty" despite being tired.
She told the coroner that, if she had known Ms Graham was epileptic, she would have enquired further about it and consulted with the on-call doctor to prescribe her medication.
Epilepsy medication not provided
That evening, Ms Graham was placed in a cell with Katie-Ann Maree Wallis, before being provided with ibuprofen and paracetamol for body aches.
At about 9pm, Ms Graham called prison officer Kristy Turner, asking about her epilepsy tablets which were not given that night.
A nurse attended to give her withdrawal medication an hour later.
Shortly afterwards, Ms Wallis made a 13-second cell call in which she told Ms Turner that Ms Graham was having a seizure.
Having trained as a nurse, Ms Wallis starting performing CPR but it took four minutes and 50 seconds for their cell door to be opened and another minute for an emergency call to be made to St John Ambulance.
A defibrillator was used on Ms Graham, delivering four shocks.
Ms Turner told the inquest a code amber alert was initially called before it was upgraded to a code red, at the same time as another emergency was called in relation to a different prisoner.
Ms Turner described the incident as "traumatic" and a "freak night".
"I haven't got a lot of experience ... but two major codes that require hospitalisation is not something that happens usually," she said.
"I haven't had a night like that since."
Delay in delivering oxygen
Back at Ms Graham's cell, an attempt was made to deliver oxygen but the inquest was told either the oxygen machine was "not brought to the cell, or the oxygen tank attached the oxygen machine was discovered to be empty".
It took eight minutes for the oxygen to be obtained and about 30 minutes for paramedics to arrive at the cell and take over resuscitation.
St John documents indicate paramedics had some difficulty accessing Ms Graham due to the security measures at the prison.
Ms Graham arrived at Fiona Stanley Hospital just after midnight on February 21 and was taken to ICU.
She died five days later on February 26.
Prior to law reforms preventing the imprisonment of people for unpaid fines, people could pay off their fines by spending time in jail at a rate of $250 a day.
The 2014 death of Yamatji woman Ms Dhu, who died in custody after being locked up for unpaid fines totalling $3,622, sparked the law reforms, but they didn't come into effect until after Ms Graham's death.
The new laws passed by WA Parliament mean only a magistrate can send a fine defaulter to jail, and only as a last resort.
The inquest, listed for two weeks, will examinee whether Ms Graham "lost an opportunity to survive as a consequence of the time taken" for prison officers and a nurse to reach her.
It will also explore whether her "prospects of survival were reduced by the absence of the oxygen machine" and the eight minutes it took for the oxygen to be retrieved and administered.
