A WA woman who died after going into cardiac arrest while in jail for unpaid fines was only afforded the opportunity for "lifesaving CPR" because of her cellmate's "heroic" actions, after the prison's nurse rushed to her cell with an empty oxygen tank, the state's coroner has found.
Cally Graham died at the age of 31 in February 2017, six days after she arrived at the then-privately operated Melaleuca Prison in the southern Perth suburb of Canning Vale.
She had been pulled over by police the day prior for "erratic driving", before being arrested when officers found she had outstanding warrants for $11,400 worth of fines.
Less than a day later she went into cardiac arrest in her cell, and despite being revived by paramedics never regained consciousness.
Ms Graham's sister Karis told the ABC she was "confused" by the findings, and "disappointed" that the family did not receive a copy of the coroner's report before it was made public.
Conflicting messages on arrival at jail
When Ms Graham was pulled over, officers reported that she appeared drowsy, with slurred speech, delayed responses, and signs of suspected drug use.
She was later taken to Royal Perth Hospital where she told a doctor she had epilepsy and was prescribed a drug she told them she had been taking, although doctors could find no evidence it had previously been prescribed.
After later being transferred to Melaleuca Prison, she gave staff conflicting information.
At one stage she told an officer she felt sick, was withdrawing from heroin and needed medication for epilepsy, before telling nursing staff she felt "absolutely fine" and not mentioning anything about feeling sick.
"Her movements were slow, and she appeared confused, with signs of delayed reactions," WA Coroner Ros Fogliani found.
Staff put that down to Ms Graham's heroin withdrawal, an idea Ms Fogliani found was "not unreasonable".
Ms Fogliani found that while Ms Graham was not "absolutely fine", there was no sign "of Cally having a more serious underlying health condition that warranted further medical investigation", and that she did not have epilepsy.
Empty oxygen tank noticed during CPR
Less than an hour before she died, prison officers were again told Ms Graham had been unwell and vomiting intermittently, although it was still put down to drug withdrawal.
Not long after, her cellmate — who happened to be a qualified enrolled nurse — heard a "gurgling" noise before realising Ms Graham had stopped breathing. The cellmate quickly started CPR, including "rescue breaths".
Ms Fogliani found it took just under five minutes for the overnight prison nurse to arrive at the cell with other officers, who continued CPR and applied a defibrillator.
But when they tried to give Ms Graham oxygen, they found the oxygen tank brought to the cell by the nurse was empty.
It meant the nurse and an officer had to return to the medical centre to find a new one, taking another eight minutes.
Paramedics were only called eight minutes after the initial emergency call, arriving 20 minutes later.
They estimated it took another five minutes to access Ms Graham's cell — delays Ms Fogliani put down to the prison having only recently opened, with "systems and processes ... not being fully implemented".
Family still trying to piece events together
Having taken over resuscitation efforts, paramedics were able to bring back Ms Graham's pulse before taking her to Fiona Stanley Hospital.
She was rushed into the hospital's intensive care unit, but five days later, the 31-year-old's family were told her "expected prognosis was poor".
Ms Graham died two days later.
Sister Karis Graham paid tribute to her "vibrant", "fun" and "loving" sibling.
"I love my sister, and I wish she was here to enjoy life with me, but she's gone and she's gone way too early, too young," she said.
Karis Graham said she believed her sister should have been taken to hospital much earlier.
"I'm still trying to understand how someone can lay there for 12 hours, vomiting and being sick all day and complaining and asking for their medication, and to be ignored," she said.
The coroner found Ms Graham had been given opiate withdrawal medication, which had been prescribed earlier that day, before she stopped breathing.
The findings only mention her asking to be given the epilepsy medication once, but it appears it was not administered because the prison's medical staff had not been told of its existence.
Ms Fogliani found the heroin in Ms Graham's system contributed to her death, most likely by causing an abnormal heart rhythm "that gave rise to the cascade of events leading to her death".
Standard of care 'below' what should be expected
In her findings released yesterday, Ms Fogliani "commended" the actions of Cally's cellmate, Katie-Anne Wallis.
Ms Fogliani pointed to the evidence of two doctors, who said the cut-off time for oxygen to be administered to improve the chances of surviving was between five and eight minutes.
"In either case, it took a further eight minutes for a functioning oxygen tank to become available after the nurse and custodial officers entered Cally's cell, and this was too long," she said.
"It was an unnecessary delay."
Ms Fogliani said while she accepted the chances of Ms Graham surviving "were indeed very slim," based on the evidence of two doctors, "they were not wholly absent".
"If Cally's cellmate had not performed the rescue breaths, I would have found that an important opportunity to perform effective CPR on Cally following her collapse was missed, and further that it potentially had an adverse impact upon her prospects of survival," she said.
A "functioning oxygen tank" should have been available when the nurse first arrived at Ms Graham's cell, Ms Fogliani wrote.
"I am satisfied that Melaleuca Prison's standards of care fell below what should ordinarily be expected in delivering CPR for Cally, by reason of not having a functioning oxygen tank when the staff entered Cally's cell, as a consequence of which it took a further eight minutes to make one available," her findings read.
Evidence procedures not being followed
The nurse who responded to Ms Graham's cell gave evidence that the emergency bag that contained the empty oxygen tank should have been checked on certain days, and after the bag had been used.
"In [the nurse's] experience the emergency bag was always sealed and, in an emergency, she would pick up the bag and go," Ms Fogliani found.
"There would be no time to check what was in the emergency bag, and it was her expectation that everything that was required would be in the bag.
"That there was an empty oxygen tank in the emergency bag goes to show that checking procedures were not invariably being followed at the material time, which is unsatisfactory."
The nurse had given evidence that the bag may not have been checked at the time, "due in part to staffing shortages".
Ms Graham's sister said she was "horrified" that the empty tank was not picked up earlier.
"I just can't believe that with the things that we have and the policies and procedures that we have in this day and age we have to rely on cellmates to resuscitate other inmates," she said.
Since Ms Graham's death, oxygen tanks have been added to prison units, as well as in emergency bags.
The inquest had also been told procedures around checking the contents of emergency bags had been updated.
Improvements made: medical service
In 2017 Melaleuca Prison had only recently opened and was "in its infancy", with procedures and staffing issues "still being worked out".
It was being privately run by Sodexo Australia, who subcontracted medical services to a company called Aspen Medical.
In mid-2020, management of the prison was returned to the Department of Justice.
In a statement, a spokesperson for Aspen Medical "commended" all those involved in the incident, and said it recognised the "ongoing loss" experienced by Ms Graham's family.
"Investigation and reflection of this incident provided an opportunity to ensure we can all do better, and as such, we set about improving processes and procedures in the immediate aftermath of the incident at this site, and across our entire organisation," the spokesperson said.
The Department of Justice issued a statement on Friday saying all deaths in custody were taken seriously, and systems and processes were always reviewed in light of coronial findings and recommendations.
It said it noted that in this case, the coroner recognised improvements had been made at government-operated WA prisons regarding the availability and checking of functioning oxygen tanks, and as such made no recommendation.
Returning Melaleuca to public operation was an unrelated decision by the government, it said.
WA's unpaid fine laws were reformed in 2020 to make jail a last resort for fine defaulters, which could only be ordered by a magistrate.
