Mr A died of a heart attack. He complained of chest pains and his room-mate pressed the emergency call alarm in the room. Healthcare staff attended, but thought his symptoms were heartburn and he was told the doctor would see him next day.

The room-mate pressed the emergency alarm again and the detention officer found the complainant in bed and unresponsive.

In spite of first aid training, the Healthcare staff did not attempt resuscitation, nor did the next two custody officers do so on arrival in the room. Two nurses came with a resuscitation bag and oxygen cylinder and began CPR. One nurse went back to get the defibrillator but it did not have a battery and could not be used. Finally an ambulance was called, but Mr A could not be resuscitated.

The inquest concluded that neglect contributed to his death and there had been a total breakdown in his healthcare.