A doctor who unsuccessfully tried to revive an Aboriginal man who died after repeatedly screaming “I can’t breathe” while prison guards held him down has admitted he made mistakes in the process of giving CPR.
Dunghutti man David Dungay was 26 when he died in the hospital within Long Bay jail in Sydney on the afternoon of Dec. 29, 2015.
A video of Dungay’s last moments shows corrective services officers storming Dungay’s cell, restraining him and moving him to a different cell as he screams “I can’t breathe” repeatedly in a high, agitated voice.
After a nurse injected him with a sedative in the second cell, Dungay became unconscious and could not be revived.
These events occurred after Dungay, a diabetic, refused to stop eating a packet of rice crackers, and there was concern the crackers might affect his blood sugar levels.
A coronial inquest into the death began in July last year and ran for two weeks before it was adjourned due to a long witness list running over schedule.
It resumed on Monday morning at the Coroner’s Court in Lidcombe, where nurses Netra Thapa and Rajana Maharjan gave evidence about the CPR they and other medical staff had administered to Dungay.
Thapa said he was aware an expert witness, associate professor Anthony Brown, had criticised the CPR effort. He said while he believed staff had done their best there was “always room for improvement”.
“It was a challenging situation and we all were distressed,” he said. “We were doing our best to revive the patient given the circumstances … I think we did our best in the best interests of the patient.”
Thapa agreed there were periods of time where Dungay was not receiving any chest compressions or ventilation of his airways.
“When I look back on the video I can see some interruptions there, yes,” he said.
Maharjan said staff were “struggling to open [Dungay’s] airway” as he regurgitated food.
“There was lots of food particles coming out from his mouth every time we did the CPR … we were using handheld suction,” she said.
Dr Trevor Ma, who was employed at the jail hospital as a psychiatric registrar in 2015, performed chest compressions on Dungay during the 17 minutes in which Justice Health staff attempted to revive him.
Ma said he was aware Brown had criticised the lack of consistency in chest compressions and the fact there were “substantial breaks” where none were done during the course of CPR.
“Do you accept those things could have been done better and more consistently?” asked counsel assisting the coroner Jason Downing.
“Definitely,” Ma replied.
Ma, who has left Long Bay Hospital and now works as a consultant psychiatrist in other correctional settings, said he felt a “responsibility” to try to lead the CPR as Dungay was his patient.
“In hindsight, I clearly didn’t do that efficiently,” he told the court. Asked if he had discussed with the nurses what role they should take in the resuscitation, he answered, “Unfortunately and regrettably no. It was a pretty frantic situation. We all just wanted to be active and do what we knew we could do.”
Thapa said a new policy, now in place at Long Bay, which puts a single person in charge of coordinating CPR during emergencies, would lead to “better team collaboration” if the same incident happened today.
“There is [now] a clear sort of task delegation,” he said. “Everybody is on the same page, who does what. Rather than chaos [where] nobody knows what they’re doing.”
All three medical staff said the Dungay emergency was the first time they had ever been called to give CPR on a real person, as opposed to a training dummy.
The inquest is also considering why Dungay was moved to a different cell when he became agitated after being asked to stop eating biscuits.
Whether or not it was necessary to move him at all is a central issue in the inquest.
Officer F, who cannot be identified for legal reasons, testified last year that he had made the decision to move Dungay based on a request from Justice Health medical staff.
Maharjan contradicted this in her evidence, saying officers had come to her requesting a medical certificate to move Dungay to a cell with a camera in it.
“The clinical issue David was having at that time was only high blood sugar level, and that could be managed in a no-camera cell with an increased level of observation,” she said.
Maharjan said she asked a doctor whether to move Dungay, and he told her to leave him in the no-camera cell for now while they devised a new plan to manage him.
Maharjan said she went back to the ward and relayed this to officers, but could not recall exactly whom. She said she believed Officers E and F were there at the time.
Ma told the court he had no recollection of Maharjan asking him about whether a medical certificate should be granted to move Dungay.
The inquest continues.