On Thursday, a NSW coroner ruled a 29-year-old man's death in custody in 2022 was “preventable”.
Dictor Dongrin died one day after being taken to a correctional facility in northern NSW. At the time, he had symptoms of alcohol withdrawal.
Judge Rebecca Hosking described the facility’s staff’s care of Dongrin as “wholly inadequate” and recommended a review.
Here’s what to know.
Inquest
In NSW, a coronial inquest is held when a person dies in “sudden or unexplained” circumstances, or when there are “unresolved issues” left from an initial investigation.
They are always held when a person dies in custody.
An inquest is not the same as a court hearing, and a corone
r cannot find someone guilty of a crime.
At the end of an inquest, the coroner may make recommendations on ways to improve public health and safety.
Background
On 11 June, 2022, 29-year-old Dictor Dongrin and his brother were charged after an alleged attack on their father at a family home near Coffs Harbour.
At Coffs Harbour Police Station, Dongrin was deemed moderately intoxicated. He was refused bail and taken into custody.
Before being transferred from the police station to the Clarence Correctional Centre (CCC) the next day, a corrections officer noted he required medical review due to being at risk of alcohol withdrawal.
CCC is managed by the company Serco.
A person can go into alcohol withdrawal if they stop drinking after a long period of heavy consumption.
The inquest heard Dongrin was drinking four to six litres of wine a day in the lead-up to his arrest.
On his arrival at CCC around 12.30pm on 12 June, Dongrin was assessed as having an Alcohol Withdrawal Scale score of eight out of 10, with symptoms including shakiness and sweatiness.
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He was placed in a medical observation cell. Staff watched CCTV but did not directly interact with him from 10pm that night until 1.30pm the next day when he was discovered to be dead.
Findings
Hosking said CCC staff’s “treatment, healthcare and management” of Dongrin was “wholly inadequate”.
She determined that better care “could have prevented Dictor’s death”.
In a recording played at the inquest, Senior Nurse Practitioner Cassandra Holland was heard to say Dongrin was dead at 1.42pm, then turn to others and ask “who’s not done CPR?... This is a training exercise now only”.
Hosking said the recording “must have been highly distressing for [Dongrin]’s family to hear”.
“Dictor’s death was preventable and it occurred while he was in custody, powerless to protect himself," Deputy State Coroner Judge Rebecca Hosking delivering her findings on 11 June.
Recommendations
Hosking recommended Serco assess its staff’s knowledge of alcohol withdrawal protocols, and clarify responsibility for patients in medical observation cells.
The inquest heard Serco had introduced improved observation, handover and training protocols since Dongrin’s death. However, the coroner found further reforms were needed.
Hosking recommended allowing staff at privately operated prisons to access the full patient records available in government-run facilities, such as hospitals.
The coroner also referred three health practitioners to their professional oversight bodies, including Holland.
Hosking said Holland’s actions during CPR fell below the standard expected of a practitioner at her level.
The Medical Council of NSW has been asked to review the on-site doctor’s treatment and management of Dongrin, including the prescription and care plan during his custody.
Response
Dongrin’s parents, Rebecca Deng and Moses Dongrin, attended every day of the inquest.
In a statement provided to the court, Moses Dongrin said: “Everyone in this world has a role to play. If my son’s role was to change the way people are treated, that’s okay with me.”
Hosking said she hoped the recommendations would honour Dictor’s memory and help prevent similar deaths in the future.
