Royal Commission into Deaths in Custody Report of the Inquiry into the Death of the Young Man who died at Beatrice Hill Prison Farm on 21 September 1988
Tabled Paper 118
Tabled Papers for 6th Assembly 1990 - 1994; Tabled Papers; ParliamentNT
1991-02-14
Tabled by Marshall Perron
Made available by the Legislative Assembly of the Northern Territory under Standing Order 240. Where copyright subsists with a third party it remains with the original owner and permission may be required to reuse the material.
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https://www.legislation.gov.au/Details/C2021C00044
https://hdl.handle.net/10070/294123
https://hdl.handle.net/10070/396790
Dr Lee gave consideration to the matter of resuscitation and was able to tell the Coroner: The big difficulty with BCF poisoning and in all these volatile and gaseous poisonings is that the effects come on extremely rapidly and unless very efficient resuscitation can be started extremely quickly then there is usually not much chance of recovery so it would be very hard to suggest anything other than having somebody fully trained available all the time. From this, it appears that once the deceased collapsed, there was nothing that could have been done, by way of resuscitation, to save his life. The Coroner correctly found that to be the case. The inhalation of BCF caused the deceased to vomit, which was subsequently inhaled and would itself have been part of the mechanism of death. Before resuscitation could be effective, air passages had to be cleared, and intubation is the process by which material could then be sucked from deep air passages. The nearest suitable personnel and equipment for such purposes was in Darwin. With whatever speed they were brought to Beatrice Hill, it would, as Dr Lee said, have been too late. The ambulance in fact took thirty-four minutes from the time of call to arrival. Police Investigations The inquest into this death occupied nine days and thirty-two witnesses gave evidence covering all relevant aspects of the Coroners inquiry. This reflects a competent investigation by police. Indeed the Coroner analysed the police investigation in an additional finding to which I now refer: Accordingly I believe it is appropriate to make the following additional findings and recommendations when required. 18