Nurse failed to check woman before death

·3-min read

A registered nurse failed to check on Veronica Nelson's condition in the hours before her death at a Melbourne women's prison, a coronial inquest has heard.

A doctor at the Dame Phyllis Frost Centre planned for Mark Minett to check Veronica's heart rate, blood pressure, and general condition on the afternoon of January 1, 2020, after assessing her earlier that morning.

But in his evidence to the Victorian Coroners Court on Friday, Mr Minett admitted he did not assess Veronica, saying it was a missed opportunity to notice her deteriorating condition.

Veronica died in a cell the next morning from complications of Wilkie's syndrome, in a setting of withdrawal from heroin.

The Yorta Yorta woman was given electrolytes and an injection to help with dehydration in the doctor's assessment on the morning of January 1.

Checks showed she had high heart rate of 123 beats per minute, but the court heard the doctor noted Veronica was "alert and orientated, and not unwell".

The doctor's notes, which were shown to the court, also said a nurse would review Veronica later that afternoon, with observations of her vital signs to be taken.

Mr Minett said he did not remember being told to undertake the review, but he conceded there was a plan in place that he did not follow.

The court heard Veronica vomited five times that day between 11am and 2pm, but Mr Minett said he was not aware of her condition.

He told the court he believed Veronica was being moved away from the medical unit to another area of the prison, and her symptoms appeared consistent with heroin withdrawal.

A psychiatric nurse at the women's prison, Bester Chisvo, told the court she had been concerned medical staff were not monitoring Veronica closely.

Ms Chisvo assessed Veronica on December 31, 2019, when she was first brought into the Dame Phyllis Frost Centre.

Veronica appeared to being going through significant heroin withdrawal at the time and was repeatedly vomiting, Ms Chisvo said on Friday.

During their brief consultation, Veronica was unable to sit up in bed, Ms Chisvo said, and was polite and cooperative but disorientated when asked questions.

The psychiatric nurse told the court Veronica did not disclose or appear to have any mental health concerns, although it was obvious she was physically unwell.

Notes presented to the court showed Ms Chisvo recommended custody officers keep Veronica in the medical unit overnight so she could be monitored.

In her evidence, Ms Chisvo said she also told the nurse on duty that Veronica needed to be medically monitored while in the unit.

But there was no record of that happening, Ms Chisvo told the court.

When she returned to work on January 1, the nurse told Ms Chisvo she had seen to Veronica but there was no notation of such monitoring on Veronica's file.

"You could tell this woman was physically unwell and she needed further intervention," Ms Chisvo said.

Evidence will continue in the coronial inquest on Monday.

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