A Perth woman who died in custody after being arrested for unpaid fines may have been robbed of ‘a chance to survive’ due to delays in responding to a call that she was having a seizure, a source has claimed. investigation.
- The inquest heard there were delays in providing medical treatment to Cally Graham
- This included delivering oxygen when she suffered a seizure
- The court was told Ms Graham had not been given her epilepsy medication
Cally Graham was 31 when she died on February 26, 2017 after being jailed at Melaleuca Remand and Rehabilitation Center for failing to pay fines.
It took five years for an inquest into his death to be heard, which his 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 sadly my dad didn’t survive the wait for the inquest.”
State Coroner Ros Fogliani offered his condolences to the family of Ms Graham, who attended the first day of the inquest at Perth Magistrates’ Court on Monday.
Witnesses began to piece 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 administering oxygen to Ms Graham as she was having a fit.
The timeline of events emerges
Ms Graham was arrested for a series of unpaid fines on February 19, 2017 – the largest of which is believed to have been just over $700 – and taken to the Perth Watch House in Northbridge, where a nurse noticed she seemed “drowsy”.
After telling the nurse she had epilepsy, she was transferred to the Royal Perth Hospital and prescribed the epilepsy drug Lyrica.
Back at the Watch House, her medications were sealed and labeled, but they weren’t listed on the property receipt “for reasons that are unclear.”
Ms Graham was then transported to Melaleuca Institution where she told prison staff that she had gone to the hospital to get medication for epilepsy, that she was withdrawing from heroin and that she felt sick.
Registered nurse Ann-Marie Brennan conducted a health assessment but said Ms Graham did not mention a history of epilepsy or medication.
Ownership records showed that the Lyrica issued to Ms Graham at the hospital was received and documented by the facility, but the Department’s Custodial Deaths Report suggested it was done the following day, after Ms. Graham had left. Mrs Graham.
Ms Brennan said her observations, including pulse and blood pressure, were stable and she was ‘quite talkative’ despite her fatigue.
Ms Brennan told the coroner that if she had known Ms Graham had epilepsy, she would have inquired about it and seen the doctor on duty to prescribe her medication.
Epilepsy drugs not provided
That evening, Ms Graham was placed in a cell with Katie-Ann Maree Wallis, before being given ibuprofen and paracetamol for body aches.
At around 9 p.m., Ms Graham called prison officer Kristy Turner to ask for epilepsy tablets which had not been administered that evening.
A nurse came to give him withdrawal medication an hour later.
Shortly after, Ms Wallis made a 13-second call during which she told Ms Turner that Ms Graham was having a seizure.
Trained as a nurse, Ms Wallis began 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. St John Ambulance.
A defibrillator was used on Ms Graham, delivering four shocks.
Ms Turner told the inquest that an amber code alert was initially called before being upgraded to a red code, at the same time another emergency was called regarding another prisoner.
Ms Turner described the incident as ‘traumatic’ and a ‘weird night’.
“I don’t have a lot of experience…but two major codes that require hospitalization is not something that usually happens,” she said.
“I haven’t had a night like this since.”
Delay in oxygen supply
Back at Mrs Graham’s cell, an attempt was made to supply oxygen, but the inquest was told that the oxygen machine ‘had not been brought into the cell, or that the oxygen tank oxygen attached to the oxygen machine was empty”.
It took eight minutes for oxygen to be obtained and approximately 30 minutes for paramedics to arrive at the cell and provide resuscitation.
St John’s papers say paramedics had difficulty gaining access to Ms Graham due to prison security measures.
Ms Graham arrived at Fiona Stanley Hospital just after midnight on February 21 and was taken to intensive care.
She died five days later, on February 26.
Prior to legislative reforms preventing people from being jailed for unpaid fines, people could pay their fines by spending time in jail at $250 a day.
The 2014 death of Yamatji’s wife, Ms Dhu, who died in custody after being locked up for unpaid fines totaling $3,622, sparked the law reforms, but they only came into effect after Ms Graham’s death.
New laws passed by the Western Australian Parliament mean that only a magistrate can send a fine offender to jail, and only as a last resort.
The inquest, scheduled to last two weeks, will examine whether Ms Graham ‘lost a chance to survive because of the time taken’ by prison officers and a nurse to reach her.
It will also explore whether his “prospects for survival were reduced by the absence of the oxygen machine” and the eight minutes it took for the oxygen to be retrieved and administered.