Report on Inquest 5 March 2019

Coronial Inquest into David Dungay

Deaths In Custody

DAY TWO 05/03/2019


  • Lack of Medical Intervention: Categorised within forced medication
  • Lack of training for authoritative Correctional staff dealing with prisoners
  • Failure in identifying the ramifications associated with the medical intervention towards David Dungay
  • Errors in medical judgement

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

Witness Statement 1 – Dr Ma

Dr Ma was an accredited medical practitioner who initially carried out the forced medical treatment on David Dungay. Dr Ma was aware of the medical condition of David Dungay and has intervened in this treatment.

Identifying traits in patients medical condition:

Dr Ma reiterates that the patient has ‘impaired judgement.’ From this case it would be relevant to consider that David Dungay’s behaviour and medical diagnosis is relevant in proving the mitigating factor of this case; as he acts impulsively rather than rationally due to the mental impairment associated with his medical condition.

Errors in medical judgement

There was no accredited third party auditing service provided in regards to emergency training practices. In addition, professional staff failed to de-escalate the patient’s aggravated behaviour, resulting in a breach of their level of care. In regards to this case, there was a failure in liaising directly with professionals within the appropriate hierarchy stipulated, resulting in a lack of confidence within the Health Department. David Dungay’s state of vulnerability was exacerbated by the neglect of staff officials in making appropriate observations of his physical state.

In regards to the CPR medical training prerequisite, Dr Ma further corroborated that it was an “Appalling attempt at resuscitation,” and that it was certainly not up to his standards.

The liability falls against Dr Ma, as the medication to be administered was beyond the duties of the Nurses, yet Dr Ma still instructed them to administer it. The argument in which defends the initial purpose of Dr Ma’s actions is that these nurses were highly experienced and he believed that they could undertake such tasks. Dr Ma believed that his area of control was in reading the notes and assessing the circumstances.

Witness Statement 2 – Chief Trainer for Justice Health Staff; Mr Sontag

Mr Sontag is affiliated in the field of health and is a Chief Trainer for Justice Health Staff, including nurses. Mr Sontag was involved in the case of David Dungay, whereby he administered the training and education of the Nurses. Sontag is involved in various training programs; such as the ‘Myrtle Program’ and other various initiatives.

Lack of training and education for Nurses

The lack of administering the appropriate approach to training and education was evident, seen through the inadequate procedures undertaken for CPR on Mr David Dungay. This is highlighted through the role of Nurse Maharja, who was cross- examined about the training content on the 04/03/2019.

The lack of induction training and education is clearly indicated through the inadequate intervention in possibly saving David Dungay’s life. Mr Sontag confirmed that the video evidence showed that there was difficulty in air passage. He confirmed that the cap was left on the suction device, as well as the neglect in examining who was responsible for this. Mr Sontag reiterated the notion that there is a prevalent issue in the structure of leadership within nursing practices, which demonstrated a lack of confidence.

Compliance with Australian Standards

Mr Sontag affirmed that there is no audit of medical emergency training practices, as he stated that these incidents are quite rare.

Witness Statement 3 – Ms Sheehan

Ms Sheehan is Deputy Director of Midwifery and Custodial Services. She presented existing health policies on Enforced Medication.

Policies for Medical Practices

Ms Sheehan stated policies in relation to PRN medical patients, the need for de-escalation actions by nurses, and the Enforced Medication and the Emergency sedation policies and practices. She recommended for these policies to be brought in line with current NSW Health Policies.

Ms Sheehan further gave evidence that a nurse could make a decision in regards to intramuscular injection of midazolam on a PRN patient such as Mr David Dungay.

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