Azroy Dawes-Clarke (1)

“communication between attending prison staff, healthcare professionals and paramedics was confused. There was confusion as to who had command and control of the medical emergency, which public body took primacy and the difference in roles and responsibilities. Those attending the scene did not establish any sort of communication strategy or command structure. During prevention of future deaths evidence, there remained a lack of clarity and consistency as to how such a situation would be avoided if a critical medical emergency eventuated in a custodial setting again.”