Blackbutt killer died as nurses debated CPR
AN HABITUAL violent criminal with a terminal illness died covered in his own vomit while nurses debated whether they should start CPR.
The findings of a coronial inquest into the death of killer Michael Leslie Burrell were handed down on Friday and revealed the circumstances around his death in the prison ward of one of Queensland's busiest hospitals.
The wheelchair-bound prisoner was in palliative care in Princess Alexandra Hospital's secure ward for one day before he died from an apparent respiratory and cardiac arrest on September 18, 2016.
He was found in his cell covered in faecal vomit.
Burrell was serving a 10-year prison sentence for manslaughter after stabbing his friend Norman Goetze to death after a night of drinking in Blackbutt in 2007.
At the time of his death, Burrell had been suffering from liver cancer for several years and hepatitis C for more than a decade.
He had also relied on a wheelchair since a drunken car crash in 1997 that led to his right leg being amputated below the knee.
Burrell was taken from Wolston Correctional Centre and admitted to hospital a day before he died with nausea, vomiting and abdominal pain. The coronial findings show his condition deteriorated overnight before his treatment was handed over to morning shift nurses at 6am the following day.
By 6.30am, nurses checking his condition found him with blue, mottled skin that was cold to the touch. The inquest findings show they requested morphine when he began thrashing and attempting to speak.
Ten minutes later, the nurses returned to find Burrell unconscious and covered in black faecal vomit. He was not breathing and had no pulse.
The nurses called a code blue and discussed whether to start CPR.
"It was determined that they would not do CPR as Mr Burrell was assessed as not showing any signs of life and CPR would be futile," the inquest states.
"CPR was also not considered feasible due to the presence of faecal matter on Mr Burrell, and the risk of hepatitis C infection to the nurses if they performed CPR was too great."
The inquest shows it took 14 minutes for rapid response team to sign in with secure ward security and attend the code blue.
Coroner Terry Ryan also found nursing staff twice failed to adhere to hospital procedure during Burrell's treatment, including during the debate on CPR.
Human error also contributed to a missed x-ray showing a bowel obstruction.
After an internal hospital review, a dedicated code blue phone line has since been installed in the secure ward to prevent delays in responding to future code blues for prisoner patients.
The coroner did not make any recommendations and found systemic errors in Burrell's treatment did not contribute to his death.
He said the human errors that did contribute to Burrell's death did not mean staff were at fault.
"It was necessary to assess the actions of those staff in the context of the circumstances at the time," he said.
The ultimate cause of death was found to be due to Burrell's liver cancer and hepatitis C.
Cancer is one of the leading causes of deaths of prisoners in Queensland.
Up to 2% of prisoners have or have had cancer on entering prison according to the Australian Institute of Health and Welfare's latest prisoner health report. A total 30% have at least one chronic condition.