Report on Inquest 4 March 2019

Coronial Inquest into David Dungay

Deaths in Custody  

DAY ONE 04/03/2019


  • Significant lack of training for correctional and medical staff in emergencies that require intervention.
  • Uncertainty surrounding Dungay’s behaviour and the extent of his aggression.
  • Witnesses reluctant to take responsibility, admit guilt or fault.
  • Revision of sedation/enforced medication policies and other safety procedures.
  • Unjustified choices/doses of medication used.

Below is a summary of the evidence given by two key witnesses in the case.

Witness Statement 1 

Relationship with Patient

To open the inquest, Rajana Maharja was brought to testify her movements during the death of David Dungay on the 29th December 2015. Rajana was a nurse at the correctional facility where David Dungay resided. Maharja explained that her prior dealings with Dungay were “occasional” and of which she recalled she knew him as a patient in Ward G of Long Bay Hospital.

Diabetes Management

On the date of the death, Maharja stated that the nurses (Zhu, Thapa and Newman), doctor (Dr Ma) and herself were all knowledgeable of the concern surrounding Dungay’s diabetic management. This included the fact that Dungay had consumed rice biscuits and as a result, quickly became agitated when instructed to stop consuming by a custodial officer. Nurse Zhu recounted this incident to her.

Maharja was questioned on what occurred after she had this conversation with nurse Zhu. Maharja claimed that she spoke to unidentified officers who requested Maharja write a medical certificate that would allow Dungay to be moved to a camera-cell.

Maharja told the court that her only concern with the biscuit incident was in regards to the risks it posed to Dungay’s sugar levels, which would be expected to fluctuate. Being a ‘clinical issue,’ Maharja expressed that this was a “clinical issue” which did not need to be dealt with by placing Dungay in a camera-cell – her opinion was in opposition to the custodial officer’s who intended to increase observation of the innate as per ‘procedure.’ 

Response to Patient’s Agitation

Maharja explained that she was located in the medication room when the ‘duress button’ sounded. Maharja claimed that herself, nurse Newman and Doctor Ma responded by beginning to resuscitate Dungay.

There was no indication in testimony of how, who or when the duress button was pushed, or if protocol was being followed as per outlined in Doctor Ma’s testimony (vitals being checked every 15 minutes until mobilization).

When asked what her role was in the resuscitation of Dungay, Maharja stated that she had great difficulty in recalling and expressing her actions due it being a high stress situation. However, she described her primary role being to maintain the airway by holding the jaw open and to get the air bag valve mask. She was prevented from doing so due to the excess amounts of thick vomit that was caused by the biscuits he had digested.

Nurse Newman assisted Maharja in opening the however, claimed that the food particles became too difficult to remove, and so attempted to perform a ‘hand-held suction.’ Maharja also states that Nurse Thapa came from another ward to assist – she does not recall her primary role in the incident. According to Maharja, Dr Ma was performing chest compressions.

Emergency Specialist Dr Brown has since criticised the actions of those involved in the resuscitation incident as adequate ventilation was not consistently provided to Dungay.

Questioning the Witness

Maharja was asked about her qualifications in CPR. She explained that the incident was her first experience performing CPR in a real emergency situation and not in simulation or educational role plays.

When asked about her training for emergency CPR since this incident, she struggled to recall when or what training she had completed in reference to new policies instigated by Justice Health. However, Maharja did state that a new team leader was appointed in the area of Emergency Training Services. The leader’s role is to ensure adequate execution of response checklists and foster more collaboration between Justice Health staff and Corrective Officers.

Maharja did claim to do further simulation based scenario training following the incident. When asked what she would have done differently in the incident, she said these new policies and plans would be implemented. Maharja and staff are alerted to changes in framework via headboards/emails. The discussion of frameworks was vague – Maharja has not been in similar situation of emergency resuscitation since 2015.


At this point the court had a break and the conclusions are as follows:

There has been poor training in respect to roles and responsibilities in areas of sedation and joint intervention – evidence drawn from witness statements demonstrates inexperience and incompetence.

Restatement of Facts

As court resumed, Maharja was once again questioned on her knowledge of the transfer, to which she claimed she was in the nurses station and did not see the transfer of Dungay from a non-camera cell to a camera cell.

She was also further questioned on her resuscitation training to which she added information about her first year of Nursing which included scenario based training at Long Bay Hospital learning centre. This detect training incorporated CPR training – the CPR coordinator acting as one of the educators in this course which she completed some time after starting in March 2013. Records from Justice Health indicated that she had not completed training since the 8th of April 2014, 20 months before Dungay’s death.

In response to not having completed a refresher course of CPR, she claimed she was on annual leave and not aware that her CPR course had lapsed, to which both parties are responsible to follow. Even though she had not done any practical CPR training in the fourteen months preceding Dungay’s death, she claimed to be confident in her skills as she had been assessed and checked whether she was competent or not in being assessed on a mannequin previously.

Maharja was questioned again about her roles during resuscitation (resuscitation lasted 17 minutes). Maharja claimed she and a colleague were working on the airway at the same time. Additionally, Maharja mentioned that at one point, a defibrillator was used on the victim’s chest. She was asked how long it takes for a defibrillator to deploy based on her experience, she could not answer for sure. She also cannot recall why there were long pauses taken between the 30 compressions and 2 breaths that should not have occurred (in line with proper CPR practice). She could not recall who completed the suctioning, or that a cap was left on the suction device, which was later found in Dungay’s mouth.

Following the Event

Maharja was asked whether she had continued to work in G Ward after Dungay’s death, to which she has (continuously and reasonably). She has also worked in the E and F Ward which are Mental Health Units.

Maharja was questioned on how practices have changed in enforced medication since Dungay died, to which she claimed there was now joint intervention with custodial services, and less enforced medication policies. She was also asked about the use of safety huddles in the Ward, which she claimed to occur at around 9-9:30 in the morning when doctors are around, however, was unsure whether these were used at the time of Dungay’s death.

Witness Statement 2

At this point, Dr Trevor Ma was brought in to answer questions. His representation raised an objection and under section 61 of the Coroner’s Act, to giving evidence regarding any aspect of the resuscitation unless provided with a certificate under 61(5) which would deem him potentially liable to civil penalty if the evidence proves. This certificate was granted.

Dr Ma offered condolences to the family, and wants to know more information about what occurred on the 26th December 2015. Dr Ma was a Psychiatric Registrar in 2015 working at the Long Bay Hospital for Justice Health, however is now working as a Staff Specialist at the Forensic Hospital adjacent to Long Bay Hospital and Silverwater Mental Health Screening Unit.

Details of Events

Dr Ma claimed that on the 29th December, a call was made by nurse Newman to raise the fact that there had been an attempt to move biscuits from Dungay. He did not know if this has occurred by physical means or a verbal de-escalation. He approved 10ml of midazolam and also 10ml Haloperodol to sedate Dungay based on his levels of aggression which the nurse has described as high. He was aware of Dungay’s diabetic condition.

Prescribing Medication

Dr Ma was asked whether about practices which involve examining the prisoner before prescribing – he claimed that there was a need to review Dungay, but it could be done before of after, as a review can occur after the mediation is administrated depending on the immediacy of the risk.

He was also asked to determine what was required in observations of the inmate following the administration to which he replied that prior to administration observations included – decreasing levels of consciousness, acute medical conditions, particularly off airway and breathing conditions and vital sign observations if possible. Following the administration of medication the patient should be continually observed every 15 minutes until the patient is mobilised.

Dr Ma also claimed that flumasinol injections were not available at this time (evidence to counteract an overdose of midazolam). In the event of his aggression, it was important to maintain the safety of the staff who are administering treatment.

Dr Ma explained that when the alert occurred over the intercom, Dr Ma found Dungay unresponsive in a G Ward Cell. Originally, he thought that he might have aspirated on the biscuit and therefore began a resuscitation approach following the DRABCD method. He admits to checking the pulse and noticing that there was some food content and blood but not a major blockage. At this stage he chose to take part in chest compressions – of which he received training during basic life support in CPR on the 4th February 2015.

As a senior doctors and having additional training over the other staff (nurses) he undertook a leadership role in which he admits in hindsight he did not do efficiently, but at the time he did what was necessary. However, in his training he had only practiced on a mannequin as per certification – there was no training of assigning of roles managing for chaotic situations.


When asked if Dr Ma saw evidence of the chest rising and falling (to show the lungs between supplied with oxygen) he could recall being concerned about the adequacy of the air bag valve mask and claims that he attempted to correct his technique.

Dr Ma addressed that he interrupted chest compressions in order to address the fact that the thick vomit would not easily clear from the airway which meant he decided to put Dungay into the recovery position.

Following the Event

Dr Ma was questioned on his training in emergency response to which he confirmed that he had in the annual refresher of life support (which has not changed since the death of Dungay), and an advanced life support course in 2018.

Dr Ma was asked whether he was aware of changes at the Long Bay Hospital in regards to enforced medication and emergency sedation to which he is aware of a new collaborative effort between Justice Health and Custodial Services. Dr Ma also highlighted a reform in terminology: meetings called “safety huddles” are said to provide the staff with a better opportunity to assess risk and communicate delineation of roles in restraint and nursing.

Dr Ma admitted that he did not perform the resuscitation efficiently despite being employed as a Registrar. He also admits to the absence of an explanation regarding why Dungay’s aggression was deemed ‘high’ level (in respect to the staff’s observations).

Please see ‘Report on Inquest 5 March 2019‘ for a continued recount on this Coronial Inquest.

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