Alexander Maconochie Centre staff did not appear to understand the urgency of the situation. Photo: Michelle Kroll.
A female detainee was lucky not to have died of a drug overdose in the ACT’s prison after a slow response from officers, a review has found.
The review found that a lack of staff also contributed to a “below optimal” response to the incident at the Alexander Maconochie Centre (AMC) on 21 May 2024.
ACT Custodial Inspector Rebecca Minty’s review of the suspected heroin overdose has been tabled in the ACT Legislative Assembly, making eight recommendations.
The review found that a contributing factor to the slow response time was the low staffing on the night shift, which resulted in no one being in the closest officer station to the woman’s cottage at the time of the incident.
Several detained women attempted to revive her, including giving CPR, while another tried to alert officers on an intercom phone to the Master Control Room, and by banging on the entrance door to the pod to attract the attention of anybody in the unstaffed officer’s station, located in a nearby building.
After some delay in connecting, the call reached the Master Control Room operator who called a Code Blue (medical emergency).
Officers and Justice Health Services nurses responded, entering the cottage five minutes later to provide first aid, including oxygen. The woman regained consciousness shortly after and was later taken by ambulance to Canberra Hospital.
The review said that with only one officer in the Master Control Room, the utmost urgency of the situation did not appear to be well understood and conveyed to responding officers.
The review made recommendations about the need for adequate staffing levels, as well as ensuring the Master Control Room was sufficiently staffed with appropriately experienced officers.
The incident was also not reported to ACT Corrective Services (ACTCS) senior management or the Inspector when it occurred, a significant failure to comply with incident reporting policies.
ACTCS conducted its own internal review and made three recommendations, but Ms Minty believed an independent public report was warranted given the seriousness of a suspected drug overdose in custody.
Both ACTCS and the Inspector’s review noted with concern the apparent lack of consequences for staff who did not report the incident and recommended that ACTCS immediately take action against them.
“It is fortunate that the female detained person was treated quickly once Justice Health staff arrived and she made what appears to be a full recovery,” Ms Minty said.
“The detained person was also greatly assisted by other female detained people, who administered CPR and made persistent efforts to alert authorities before help arrived.”
Ms Minty said harm minimisation must be an essential part of a prison’s drug strategy, as well as reducing the supply of and demand for drugs.
She said the availability of Naloxone, a drug that reverses the effects of opioid overdose, was crucial. She praised the AMC for having Naloxone on hand for Justice Health nurses and Custodial Officers to use after hours when there are no medical services onsite.
“This is excellent practice,” she said.
The review recommended that ACTCS consider extending this availability to detainees in accommodation units, as well as providing basic first aid training.
“Detained people may unfortunately be in the situation of being ‘first responders’ to suspected overdoses within units and cells after hours,” Ms Minty said.
“Providing detained people with direct access to Naloxone has the potential to save lives”.
The review focused on the response to the incident and did not consider how the drugs came to be in the detainee’s possession.
Ms Minty is currently undertaking a comprehensive Healthy Centre Review of the AMC as a whole, with drug supply, demand and harm minimisation a topic for investigation.
