Inquest into the death of Alen Imbrisak

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Alen Imbrisak Hearing date: 10 October 2024 Date of findings: 23 October 2024 Place of Inquest: Coroner’s Court of New South Wales Findings of: Magistrate Carmel Forbes, Deputy State Coroner Catchwords: CORONIAL LAW – death in custody – manner and cause of death during COVID-19 outbreak at Junee Correctional Centre – adequacy of care File number: 2022/23693 Representation: Counsel Assisting the Coroner: Ms S McGee, instructed by Mr J Webb (Crown Solicitor’s Office) The GEO Group Australia Pty Ltd: Ms T Berberian, instructed by Ms E Lee (Sparke Helmore) Commissioner of Corrective Services NSW: Ms J de Castro Lopo (Department of Communities and Justice) Justice Health and Forensic Mental Health Network: Mr B Bradley, instructed by Mr B Ferguson (Hicksons)

Findings: Identity of deceased: The person who died was Alen Imbrisak Date of death: Mr Imbrisak died on 26 January 2022 Place of death: Mr Imbrisak died at Junee Correctional Centre, Junee, NSW Cause of death: Mr Imbrisak died as a result of a sudden cardiac death in association with COVID-19 infection.

Manner of death: Mr Imbrisak died of natural causes whilst he was in lawful custody.

Non-publication order: A copy of the non-publication orders made on 10 October 2024 are available from the Registry.

REASONS FOR DECISION Introduction

1. Alen Imbrisak died on 26 January 2022, at Junee Correctional Centre, Junee, NSW. At the time of his death, he was 47 years of age. The day before he passed away, he tested positive for

COVID-19.

2. Professor Christopher Grainge, a senior staff specialist in respiratory medicine at the John Hunter Hospital in Newcastle and co-chair of the Hunter New England Health COVID-19 Medical Taskforce, coordinating that district’s medical responses to the COVID-19 pandemic, reviewed Mr Imbrisak’s relevant medical records for these proceedings and the postmortem report. He determined that Mr Imbrisak died of an extremely rare, sudden, cardiac death in association with his COVID-19 infection.

3. At inquest a coroner’s primary role is to investigate and make findings as to the identity of the deceased person, the date and place of the death, and the manner and cause of death.

4. When a person dies whilst being held in lawful custody, s. 23 of the Coroners Act 2009 makes an inquest mandatory as there is an expectation that the death will be independently investigated and that there will be a detailed account of the circumstances surrounding the death.

5. The focus of this inquest has been on the events that occurred at the Junee Correctional Centre, and in particular the adequacy of care that was provided to Mr Imbrisak, whether there has been an appropriate response to his death, and whether more needs to be done to protect others from a similar death.

Background

6. Mr Imbrisak was born in Germany in 1974. His mother is Croatian, and his family moved to Croatia shortly after his birth. His mother then re-partnered, and the family migrated to Australia in 1978. He has two sisters.

7. Mr Imbrisak grew up in a loving and supportive family. After finishing school, he commenced an apprenticeship as a chef. However, in his early 20s he started using drugs and then became involved in criminal offending.

8. At the time of his death, Mr Imbrisak was serving a sentence of 23 years imprisonment. He had become eligible for parole on 16 December 2021. However, parole was contingent on

him undertaking community leave, which he had been unable to complete due to COVID-19 associated restrictions, and a psychiatric assessment to inform any community based mental health care release plans.

9. He maintained the support of his mother, stepfather, and sisters throughout his time in custody and was in regular contact with them. One of his sisters and her husband were planning to support him in their home on his release into the community.

10. Mr Imbrisak was diagnosed with schizophrenia in his early 20s. This had been treated and managed adequately since about 2015.

11. However, in the context of the side effects of antipsychotic medication prescribed for his schizophrenia, it appears from his medical records that from at least mid-2017, Mr Imbrisak experienced significant weight gain and fell within the category of medical obesity on the basis of his Body Mass Index measurements. From at least July 2020, he was consistently measuring in the most severe range of obesity. He weighed in the 160kgs through the second half of 2020 and the first half of 2021. His weight was not recorded after 16 July 2021, but he weighed 176 kg at autopsy in February 2022.

12. At the time of his death, morbid obesity and schizophrenia were listed in his Justice Health and Forensic Mental Health Network (“Justice Health”) record as active health conditions.

He also had a history of drug use; at the time of his death, he was receiving methadone daily, having received methadone therapy for many years.

13. Mr Imbrisak received his first COVID-19 vaccination, Astra Zeneca, on 15 March 2021. On 23 June 2021 he received his second Astra Zeneca vaccination.

14. On 13 May 2021 he was transferred from the Metropolitan Special Programs Centre, where he had been since April 2018, to the Junee Correctional Centre.

Junee Correctional Centre and COVID-19

15. At the time of Mr Imbrisak’s death, the Junee Correctional Centre was run by a private provider, The GEO Group. This included the provision of all health services. That is, Justice Health did not deliver health services at the Junee Centre, though performed some monitoring of health services provided by GEO.

16. The GEO Group presently continue to run the Centre, however, will cease to do so from April 2025, at which time management of the Centre will be de-privatised, and Corrective Services

NSW (“CSNSW”) and Justice Health will take over the delivery of services at the centre from that date.

17. At the time of Mr Imbrisak’s death, Junee Correctional Centre was experiencing its first COVID19 outbreak, with a lengthy centre-wide lockdown, which came at a time where the impacts of the pandemic on health staff recruitment and retention saw the Centre’s health staffing level, at “crisis” level. 1 Factual summary

18. Counsel Assisting set out in her opening address the following summary of the circumstances surrounding Mr Imbrisak’s death.

19. On the morning of 25 January 2022, at approximately 9am, Mr Imbrisak received his daily methadone. CCTV footage of a few minutes’ duration shows him walking to and from the room where methadone was provided, and his attendance inside that room. Other than providing a clear visual of Mr Imbrisak’s size, there is nothing remarkable about the footage.

He appears to be walking at a pace and with a gait consistent with his size. There are no obvious signs of respiratory distress or other symptoms.2

20. At approximately 10:50am, after other inmates in his accommodation area tested positive for COVID-19, Mr Imbrisak was directed to undertake a Rapid Antigen Test. He returned a positive result. Accounts written after his death of Correctional Officers and nursing staff interactions with him at this time describe that he did not appear to be unwell or sick. However, the extent of medical questioning at the time was limited to whether he was experiencing any symptoms such as a sore throat or a cough. No clinical observations were attended.3

21. Mr Imbrisak was then placed in a holding cell with three other inmates for approximately two hours. CCTV is available of this period, and he appears to have remained seated on a bench throughout this time, again with no obvious signs of respiratory distress or other symptoms.4

22. At approximately 1:30pm, Mr Imbrisak was moved into the A3 area of C Unit at Junee Correctional Centre, where COVID-19 positive inmates were being held in isolation conditions.

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23. There are no other reports of any interactions with Mr Imbrisak that day, other than retrospective confirmation of his inclusion in the evening muster and meal distribution.

24. CSNSW Commissioner’s Instruction5 at the time in relation to the management of COVIDpositive inmates at Isolation Hubs, including at Junee Correctional Centre, directed that “interactions will primarily be through the cell door trap or via the cell intercom. Provision of food, oral medication (including OST) and other items (including tablets for video visits) will be provided through the cell door hatch”. That appears to be the manner in which all interactions were had with Mr Imbrisak once he was admitted into the isolation cell.

25. At this time, the Junee Correctional Centre was in a centre-wide lockdown following an outbreak of COVID-19 which commenced on 14 January 2022.6 This was the centre’s first outbreak, with the spread of COVID within the centre previously having been avoided, despite some fresh custody inmates testing positive.7

26. The evidence indicates that by 26 January 2022, 126 inmates had tested positive.8 Throughout January 2022, 96 staff had also tested positive and a further 27 were quarantined due to being close contacts.9 On 25-26 January 2022, approximately 82 inmates were housed in quarantine or isolation. All inmates remained predominantly secured in their cells in order to facilitate contact tracing and further rapid antigen testing of inmates.10 The centre also continued to receive fresh custody inmates and transfers, who also had to be tested and quarantined.

27. Under The GEO Group’s ‘Rapid Antigen Testing’ policy, such testing had to be carried out/supervised by an “Authorised Testing” or “Supervising Officer”, which we understand to refer to health services staff.11

28. The evidence indicates that the centre-wide lockdown stayed in place until mid-February 2022.

29. The second broader and related circumstance to be considered is the staffing situation, including health services staffing, at the Junee Correctional Centre as at 25-26 January 2022.

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30. Across the centre, in the context of the outbreak in January 2022, 96 staff were required to isolate for a minimum of 10 days due to testing positive to COVID-19 and a further 27 were quarantined due to being close contacts.

31. The outbreak occurred at a time when health staffing at the Junee Correctional Centre was already, as described by The GEO Group, at a “crisis” level.

32. It is apparent from the quarterly health services and staff movement reports in the brief12 that the health staffing situation had been deteriorating, with consequent impacts on health services delivery, since mid-2021: a. Between July 2021 to February 2022, the unfilled full-time equivalent allocation of health staff steadily increased from 7.73 out of 29.13 to 12.21 out of 29.13.

b. The Health Services Manager role remained vacant between June 2021 and March 2022, though it appears to have been filled temporarily for some time in September.

33. The combined effect of the outbreak and the pre-existing staff shortages on the delivery of health services at the Junee Correctional Centre in January 2022 was described by then Junee Correctional Centre General Manager in the quarterly report to CSNSW as follows:13 “the centre-wide lockdown made it difficult to assess inmates and combined with staff having contracted COVID-19 and the difficulties with recruiting clinical staff and nurses due to the nationwide shortage saw our existing staff operating at an astonishing level to simply keep the health section operational.”

34. The GEO Group has indicated through correspondence that, at one stage in January 2022, nursing staff were reduced by nearly two-thirds, with 5 nurses on duty in the medical unit instead of the usual 13 nurses. That correspondence also acknowledges that there was a requirement to conduct daily observations of both COVID-19 positive inmates and deemed close contacts.14

35. The GEO Group’s quarterly reports indicate significant non-compliance with important health services key performance indicators under the contract for services with CSNSW, particularly 12 Ex 1 Vol 3 Tabs 77.1 - 77.5 13 Ex 1 Vol 2 Tab 68 14 Ex 1 Vol 3 Tab 79, Letter from The GEO Group’s solicitors to Crown Solicitors Office dated 9 October 2024.

during the January-February 2022 period, including in the completion of chronic health care plans, and health screening for new receptions.15

36. The GEO Group does appear to have been open with CSNSW and Justice Health about its difficulties, and taken active steps in recruitment to attempt to address the gap throughout the second half of 2021, though the situation was really not improved until about March-April 2022.16 It may, however, be readily acknowledged that the shortage of health services staffing was at this time nationwide, and not a problem unique to The GEO Group.

37. The third circumstance to consider is in relation to the transfer of COVID-19 positive inmates from the Junee Correctional Centre to the Metropolitan Reception and Remand Centre, or

MRRC.

38. On the day Mr Imbrisak tested positive, 25 January 2022, an order authorising his transfer to the MRRC was approved by CSNSW Correctional Manager Operations.17

39. The evidence indicates that such transfer was part of either a CSNSW directive issued on 11 January 2022,18 or at least an established practice at this time,19 whereby all COVID-19 positive male inmates were to be transferred into a central hub at the MRRC. No specific timeframe for transfer was mandated in any policy document, whether generally or for specific categories of COVID-positive inmates, though it appears this was generally intended or expected to be done within 1-2 days.20

40. Between 17 and 27 January 2022, some 90 COVID-19 positive inmates were transferred from Junee Correctional Centre to the MRRC.21

41. While approved on 25 January 2022 for transfer, Mr Imbrisak was not ultimately scheduled for a transfer until 27 January 2022, two days after he tested positive.

42. The available records indicate that 15 COVID-positive inmates were transferred from Junee to the MRRC on 26 January 2022.22 Noting that 26 January 2022 was a public holiday, there does not appear to have been an impact on by reason of the public holiday itself.

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43. However, there does appear to have been a backlog, with no transfers having taken place on 24 or 25 January 2022, despite more inmates testing positive on those days. Of the 15 COVIDpositive inmates moved to the MRRC on 26 January 2022, 11 of those had tested positive prior to 25 January 2022, mostly on 23 and 24 January.23 As is explained by current Junee Correctional Centre Correctional Manager Mr Meiklem in his statement, each escort was limited to 16 inmates and took account of an inmate’s classification. On 26 January 2022, all inmates for transfer were classified SMAP – being a protection classification, which was not Mr Imbrisak’s classification.24

44. Available records confirm Mr Imbrisak was one of 15 COVID-positive inmates scheduled for transfer from Junee to the MRRC on 27 January. Of the 15, at least 3 had tested positive prior to Mr Imbrisak on 23 and 24 January. Four others had tested positive, like Mr Imbrisak, on 25 January 2022.25

45. In this context of a transfer plan, following notification that Mr Imbrisak had tested positive, at approximately 5:30pm on 25 January 2022, Justice Health Senior Staff Specialist Dr Vlahovic conducted a remote desktop review or “remote triage”26 of Mr Imbrisak’s file.

46. Dr Vlahovic describes in his statement that because Justice Health does not provide healthcare in private centres (such as Junee Correctional Centre), the purpose of the remote triage he, and others, conducted of patients at private correctional centres was “only to ensure Justice Health NSW was aware of the appropriate monitoring of the patients from the moment they arrived to MRRC”. He indicates that private operators, such as The GEO Group, were not required to follow Justice Health’s triage category or guidance, and the care provided to COVID-19 positive inmates while in private centres was, to his understanding, “solely a matter for the private operator”.27

47. What the framework for the management and care of COVID-positive inmates at the Junee Correctional Centre was, and the extent to which the GEO Group was required to follow any policies and guidance from Justice Health, are matters addressed further below.

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48. Dr Vlahovic created two entries, ascribing Mr Imbrisak a risk category or level, and setting out a management plan. The first, at 5:32pm, recorded:28 “47yo, Male Currently at Junee COVID positive on 25/1/22 No clinical assessment documented by Junee staff

PMH; Schizophrenia GORD [gastro-oesophageal reflux disease] Obesity Nil other known significant medical history or regular medication documented on JHeHS Limited information regarding medical history available on JHeHS Identified risk factors for severe COVID-19 illness - YES - AZx2, June 2021, obesity Vaccination status – AZx2, June 2021 Medications - nil documented OST [opioid substitution therapy] - nil documented Allergies - NKA

PLAN For full set of observations including BP/HR/RR/SpO2/Temp to be documented on JHeHS Continue with observation as per Category documented unless Pt unwell Daily assessment of acute safety risks such as TOSH [thoughts of self-harm] and SI/HI [suicidal/homicidal ideation], for MHT assessment if required Encourage patient to drink regular fluids to avoid dehydration and symptomatic management with PRN Paracetamol or Ibuprofen as required For ROI from community GP or hospital of recent admission to be submitted Any further information obtained regarding medical history and medications/OST to be documented on JHeHS In the case of clinical concerns or deterioration, please increase the frequency of observations and contact COVID MO on 0428 961 380 to discuss further” 28 Ex 1 Vol 1 Tab 12.3

49. The second entry, made at 5:34pm, recorded (emphasis added):29 “Patient has been triaged as a Category 2 patient (medium risk) for the purposes of monitoring.

Any symptoms should be discussed with appropriate MO and Sotruvimab considered is unwell

PLAN Medium risk protocol (Category 2 patient) For nursing COVID-19 wellbeing check twice daily Please ask patient about the following symptoms:

• Fever

• Cough

• Shortness of breath

• GI symptoms (abdominal pain, vomiting or diarrhoea)

• Mental health screening questions to assess patient safety

AND Perform twice daily observations for HR, oxygen saturations and temperature check In the case of clinical concerns or deterioration, please perform a full set of observations and contact COVID MO on 0428 961 380 to discuss further”

50. Dr Vlahovic explains that he triaged Mr Imbrisak as a “category 2” “medium” risk patient per Justice Health Clinical Risk Matrix as set out in the Justice Health “Business Rules” document titled “Monitoring COVID-19 positive patients including patient-partnered monitoring”. He explained Mr Imbrisak was triaged as a category 2 on the basis that he met some risk factors, namely having a history of mental illness and obesity, however, noted he was double vaccinated.30

51. On this issue of risk, Professor Grainge opines that Dr Vlahovic’s approach to Mr Imbrisak’s case was “well within accepted medical practice at the time”.31 Professor Grainge ultimately assessed Mr Imbrisak’s risk of serious illness or death as a result of a COVID-19 as “low” rather than “medium”. Dr Vlahovic had worked on the basis of a presence of risk factors, whereas Professor Grainge worked on the basis of the application of specific risk stratification scoring tools. Professor Grainge explains that even accounting for Mr Imbrisak’s obesity, mental illness and methadone use, applying such tools, his overall risk remained “low”.

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52. Dr Vlahovic explains in his statement that his expectation following creating this plan on the late afternoon of 25 January 2022, was for twice daily observations of Mr Imbrisak to be carried out by Justice Health staff once Mr Imbrisak was transferred to the MRRC.32

53. Dr Vlahovic describes that notification of a triage outcome was recorded by way of a ‘PAS Alert’ and clinical entry in the Justice Health electronic health notes systems, however, was not directly sent to the relevant clinic unless the patient was identified as a patient of concern, which Mr Imbrisak was not.33

54. There is no evidence that any health services staff member at Junee Correctional Centre became aware of the entries made by Dr Vlahovic, or otherwise carried out any clinical observations of Mr Imbrisak at any point after he tested positive on the morning of 25 January 2022.

55. Professor Grainge is of the opinion that by not performing at least an initial set of clinical observations on Mr Imbrisak and not assessing his risk of serious illness or death following his positive COVID-19 test on 25 January 2022, there were failures in his care and management, regardless of the ultimate mechanism of death.34

56. A fourth relevant circumstance to note is what policy or guidance framework did apply to the medical management of COVID-positive inmates by The GEO Group at the Junee Correctional Centre as at 25-26 January 2022.

57. By way of The GEO Group’s labelled policy, effective from 16 August 2021, titled “Management of inmates in COVID-19 quarantine”, inmates who returned positive tests, were to be “managed appropriately under existing COVID-19 protocols”. It also stated that “inmates who have tested positive will be transferred to the dedicated COVID-19 positive location at the MRRC for more intensive management”. 35 No specific protocols were referred to.

58. The GEO Group had two other relevant policies.

59. The COVID-19 Pandemic Plan, effective 3 September 2021, identified as “Priority 1” health services to be maintained at all times” matters including the following: the maintenance of “essential medical services: triage and medication”, medically screening fresh custody 32 Ex 1 Vol 1 Tab 12 33 Ex 1 Vol 1 Tab 12 34 Ex 1 Vol 1 Tab 9 35 Ex 1 Vol 2 Tab 71

inmates, COVID testing, preliminary screening of COVID symptoms on escorts, and response to urgent medical situations.

60. The Plan noted that the advice of Justice Health was to be followed regarding the assessment, treatment, and management of inmates, however, this applied only to “new receptions and for patients presenting with fever or acute respiratory infection symptoms”. The Plan also noted that in the “quarantine hub”, “the nurse will assess temperatures and general wellbeing daily”, however, the quarantine hub was separate to the “isolation accommodation”, where COVID-positive inmates were accommodated.36

61. The Outbreak Management Policy, effective 14 April 2021, did not refer specifically to COVID, and in terms of treatment of inmates who contracted the virus, the subject of any outbreak simply stated that “acutely unwell custodial patients must be referred to Health Services as soon as possible”.37

62. By way of CSNSW labelled policy or guidance, the Commissioner for CSNSW issued on 15 October 2020 a directive titled “Management of inmates confirmed positive in isolation hubs”.

That directive stated that “governors must ensure the isolation hub is adequately staffed 24 hours a day for effective supervision and regular communication with inmates, including regular observations to monitor changes in physical or mental health”.38 This unparticularised obligation for adequate staffing to provide communication including "regular observations to monitor changes”, was the extent of custodial directions regarding the medical management of COVID-positive inmates.

63. Separately to any GEO Group or CSNSW-labelled policy or guidance, Justice Health had a comprehensive set of policies and guidance documents directed to the medical assessment, risk assessment and triage, monitoring, and treatment of COVID-positive inmates. The effect of the JH suite of material was that upon testing positive:39 a. All patients would receive a full set of observations including oxygen saturation levels, respiratory rate, heart rate and temperature.

b. All patients would then be assessed against a clinical risk matrix and triaged into a risk category by a COVID-19 Medical Officer or Nurse Practitioner.

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c. All patients will then be subject to at least daily observations, per the risk category documented by the MO or NP. Such observations were to include monitoring of oxygen saturation levels, respiratory rate, heart rate and temperature.

64. None of the Justice Health policies about the assessment, monitoring, and treatment of COVID-positive patients was nominated by Junee’s current correctional and health service managers in statements to this inquest as having applied to The GEO Group at the time of Mr Imbrisak’s death.

65. Justice Health indicates this material was available to The GEO Group on the Justice Health intranet and the material and updates were routinely communicated to partner agencies, including The GEO Group.40

66. On one view of the service contract between The GEO Group and CSNSW, The GEO Group was obliged to follow the Justice Health COVID-19 specific policies and guidance.41 There is, however, also some uncertainty about how well that material, which was being regularly updated, was communicated to The GEO Group,42 or communicated by The GEO Group management to its health services staff members, and there is no evidence about what was communicated between the parties about The GEO Group’s obligations in respect of its implementation.

67. The GEO Group’s compliance with those policies and guidance was not, at any rate, the subject of any monitoring activities by Justice Health, either in the performance of its monitoring of health services in managed correctional centres function under s 236A of the Crimes (Administration of Sentences) Act 1999, or in the specific monitoring of health service delivery at the Junee Correctional Centre that it undertook (which The GEO Group was required to submit to per the services contract between CSNSW and The GEO Group).43

68. Given the cause of death in Mr Imbrisak’s particular case, it is not relevant or necessary to making findings on such issues.

69. What is to be noted is that it is clear from the evidence that The GEO Group accepts that daily observations were required of both COVID-positive inmates and deemed close contacts,44 however, there was no medical monitoring or management of Mr Imbrisak at the Junee 40 Ex 1 Vol 2 Tab 75 41 Ex 1 Vol 2 Tab 66.1 42 Ex 1 Vol 2 Tab 67 p 10.

43 Ex 1 Vol 3 Tab 78, Letter of behalf of Justice Health to CSO dated 8 October 2024 at [2].

44 Ex 1 Vol 3 Tab 79, Letter from GEO solicitors to CSO, dated 9 October 2024.

Correctional Centre after he tested positive, beyond placing him in isolation and providing him with his regular medication, pending his transfer to the MRRC.

70. This approach was not unique to Mr Imbrisak. On 3 February 2022, a multidisciplinary group of people from Ministry of Health, Murrumbidgee Local Health District, Justice Health and the Clinical Excellence Commission visited the facility to conduct an ad-hoc COVID-19 related inspection.

71. The focus of the review was to determine the effectiveness of The GEO Group’s approach to infection control in the prevention and mitigation of the spread of COVID-19, and measures that may prevent and mitigate COVID-19 transmission during usual operations, not just under lockdown conditions.

72. One aspect of the review was the management of COVID-19 patients, and whether The GEO Group was following Justice Health procedures for the clinical care of COVID-19 patients as at 1 February 2022. The findings of the review on this aspect, based on interviews with The GEO Group’s Medical Officer and registered nurses in the Centre, were:45 a. The GEO Group does not use Justice Health COVID-19 Business Rules for monitoring positive patients.

b. The GEO Group staff do not use COVID-19 Clinical Pathways.

c. The GEO Group staff were unfamiliar with COVID-19 positive patients Clinical Risk Categories.

d. The GEO Group does not follow the process of transfer of COVID-19 positive patients.

73. It is understood that the findings were not contested by The GEO Group, and that following the review a Justice Health Nurse Manager was seconded to The GEO Group (at The GEO Group’s expense) for a two-week period to assist The GEO Group’s Health Leadership team familiarise themselves with Justice Health policy and procedure.46 26 January 2022

74. Returning to Mr Imbrisak’s particular circumstances, the extent of indirect and direct interactions with him the next day, on 26 January 2022, prior to the discovery of him unresponsive in his cell at approximately 4:20pm are reported as follows: 45 Ex 1 Vol 2 Tab 67 pp 2-3, 10.

46 Ex 1 Vol Tab 78, Letter on behalf of Justice Health to CSO dated 8 October 2024 at [5].

a. The morning headcount/muster was carried out between 6:50am-6:57am. The unit Mr Imbrisak was in had 72 inmates. There was a total of 939 inmates at the Junee Correctional Centre.47 There is no description of any observations of Mr Imbrisak at this time.

b. At approximately 8:21am, Mr Imbrisak utilised the cell knock-up system to ask when he would receive his methadone. He was told by the responding correctional officer (“CO”) it would be delivered “when they get a chance to come up”. Mr Imbrisak does not sound as though he is having difficulty breathing on the recording.48 c. At 10:47am while a CO was moving around Mr Imbrisak’s cell, Mr Imbrisak approached the door and said, “Methadone chief”, to which the CO responded “no”.

He says he offered Mr Imbrisak a phone call, which he declined. A further query about methadone was raised. The CO, in a report made after his death, noted “he seemed okay and very polite, however, was more concerned about receiving his methadone.”49 d. Between 11:30am-11:45am, the midday headcount/muster of the unit was carried out. The headcount in the unit at that time was 56 inmates (15 having been moved to escort at about 9:00am).50 There is no description of any observations of Mr Imbrisak at this time.

e. At midday, the lunch meals were distributed. Mr Imbrisak appeared to collect his lunch from the cell flap door. The two COs distributing meals later reported that Mr Imbrisak had said “thank you”, and he “presented no signs of being unwell”, though it is noted that any interaction was through the cell door only.51 f. At 12:05pm, a CO and an RN attended and provided Mr Imbrisak his methadone dose through his cell door flap. The CO later reported he appeared “in good health and spoke with medical staff” before returning to his bed.52 The RN later noted there were no concerns or issues voiced, and that he appeared to display his normal behaviour and appearance, noting no changes in his appearance from the last two days.53 Again, 47 Ex 1 Vol 1 Tab 47 48 Ex 1 Vol 3 Tab 81.1.1 49 Ex 1 Vol 1 Tab 32 50 Ex 1 Vol 1 Tab 47 51 Ex 1 Vol 1 Tab 22 52 Ex 1 Vol 1 Tab 25 53 Ex 1 Vol 1 Tab 65 p 124.

however, this interaction was limited, and the apparent purpose of the attendance being to provide medication, not to conduct a COVID-19 health assessment. No clinical observations of, for example, temperature, heart rate, respiratory rate, oxygen saturation etc., were taken.

g. At approximately 12:20pm, a female CO utilised the cell knock-up system to inform Mr Imbrisak that he was “going on the truck tomorrow” and asked him whether he had shoes. He confirmed he did, and asked if he could take his TV. The CO said “yes”.54

75. There is no record of any further interaction with Mr Imbrisak on 26 January 2022 until approximately 4:20pm, when a male CO, CO McMahon, entered his cell. The sequence of events depicted by the CCTV is as follows:55 i. From approximately 4:00pm, evening meals commenced being distributed in the unit.

ii. At 4:12pm another CO opened Mr Imbrisak’s cell door flap.

iii. At 4:15pm CO McMahon placed a meal on the cell door flap.

iv. At 4:16pm CO McMahon again placed the meal on the cell door flap.

v. At 4:18pm the other CO distributed additional rations on Mr Imbrisak’s cell door flap.

vi. At 4:20pm CO McMahon attended Mr Imbrisak’s cell door appearing to offer hot water from a kettle. A few seconds later he knocked on the door, and then entered the cell.

76. CO McMahon, described in his report that:56 “I observed his food still sitting on his security flap and called his name to get him to collect it.

At this time, I observed him lying on his back on his head [bed] with his head facing towards the rear of the cell and his feet facing towards the cell door. I called his name again thinking he was in a deep sleep. After I received no response from him and observed no movement, I entered the cell.

When I entered, I tapped [his] leg to prompt a response. I did this a few times and observed no response. I then shook his shoulder in another attempt to wake him and again received no response. I then placed my hand on his chest in order to better observe his breathing. I then noticed there was no apparent rise, fall of his chest and determined that he was not breathing.

I immediately activated Cert 1 Code White to A3 and then stated that there was an inmate with that was not breathing and non-responsive.” 54 Ex 1 Vol 3 Tab 81.2 55 Ex 1 Vol 4 Tab 81 CCTV 24h, 4pm-8pm file.

56 Ex 1 Vol 1 Tab 25

77. The available CCTV depicts 5 people exiting the office area nearby to Mr Imbrisak’s cell by 4:21:40pm, with 4 people entering the cell. A Registered nurse directed the COs to move the mattress into the pod to allow for more room. Chest compressions continued immediately, and the Registered nurse requested for “medium medical staff” to attend with CPR equipment and oxygen, before then requesting a CO to call for an ambulance to attend.57

78. A defibrillator arrived by 4:24pm, and pads were applied to Mr Imbrisak almost immediately, before being moved at 4:28pm, and no shock advised on several occasions at 4:32pm, 4:35pm, 4:39pm and 4:42pm (with chest compressions continuing).58

79. At some point between 4:26pm and 4:30pm, an ambulance was called. At 4:33pm resuscitation equipment arrived from the minimum-security health centre, with three further nursing staff arriving together, and oxygen ventilation via bag and mask was commenced by 4:37pm.59

80. At 4:42pm, nursing staff administered naloxone 800mcg intramuscularly, on suspicion of drug overdose based on Mr Imbrisak’s drug use history.60 Paramedics then arrived at 4:42pm, with further no shock advised on 4:46pm, 4:48pm, 4:50pm and 4:52pm (again with chest compressions continuing).61

81. At 4:48pm, paramedics took over chest compressions. Compressions were then stopped at 4:52pm, with a paramedic listening for heart sounds. The time of death recorded by him in the verification of death form was 4:52pm.62

82. There was, in the course of the investigation, some suggestion of a delay in the availability of the resuscitation equipment. Professor Grainge in his report explains that in patients with cardiac arrest unwitnessed by emergency medical services, where no shocks are advised or administered and there is no return of spontaneous circulation with CPR (as in Mr Imbrisak’s case), the survival rate is 0% based on data from the United Kingdom.63

83. In those circumstances, any delay in the availability of resuscitation equipment could not have had any bearing on Mr Imbrisak’s death. Based on Mr Imbrisak’s unresponsive status at the time CO McMahon entered the cell, and the absence of any response or improvement 57 Ex 1 Vol 1 Tab 39 58 Ex 1 Vol 1 Tab 46 59 Ex 1 Vol 3 Tab 79.3 60 Ex 1 Vol 1 Tab 65 61 Ex 1 Vol 3 Tab 79.3 62 Ex 1 Vol 1 Tab 6 63 Ex 1 Vol 1 Tab 8

throughout the immediate and ongoing resuscitation efforts that followed, it appears Mr Imbrisak was already deceased when CO McMahon entered his cell at 4:20pm.

84. Professor Grainge also observes that the resuscitation attempt by staff was above the standard which might reasonably have been expected of staff in a correctional facility, noting the response was quick, well-managed, involved clear leadership, appropriate clinical care, contemporaneous record-keeping and appropriate involvement of outside assistance.64

85. Testing undertaken shortly after Mr Imbrisak’s death indicated the call alarm knock-up system inside his cell was functional with no faults,65 and there is no evidence that he made any call for assistance at any time other than as outlined above.

Conclusion

86. The forensic pathologist Dr Allan Cala66 set out the pathology findings at post-mortem and his opinion as to the cause of death being SARS-COV-2 (Coronavirus) respiratory infection. Dr Cala noted that morbid obesity and cardiac enlargement were “other significant conditions contributing to the death but not related to the disease or condition causing it.”

87. The pathology findings were further interpreted by Professor Grainge in his report, with sudden cardiac death in association with infection with COVID-19 being particularised as the immediate cause of death.67 He explains that important negatives or absences in the pathology exclude pneumonitis, the process where the small airways and alveoli in the lung become inflamed, and the most common cause of death following COVID-19 infection.68

88. Professor Grainge also notes the absence of pulmonary emobolus or myocarditis, which are other potential but much less common causes of death following COVID-19 infection.69

89. It is understood these absences indicate the rarity and rapidity of the mechanism of death in Mr Imbrisak’s case.

90. I am satisfied on the balance of probabilities that the cause of Mr Imbrisak's death was sudden cardiac death in association with COVID-19 infection.

64 Ex 1 Vol 1 Tab 8 p 11.

65 Ex 1 Vol 3 Tabs 81.3-81.5 66 Ex 1 Vol 1 Tab 3 67 Tab 8, First report of Professor Grainge, pp 8-9.

68 Tab 8, First report of Professor Grainge, p 8.

69 Tab 8, First report of Professor Grainge, pp 8-9.

91. I am satisfied that Mr Imbrisak’s care and treatment was adequate while he was at the Junee Correctional Centre.

92. I extend my deepest sympathies to Mr Imbrisak’s family.

93. I close this inquest.

Findings pursuant to section 81(1), Coroners Act 2009 Carmel Forbes Deputy State Coroner Coroner’s Court of NSW, Lidcombe Date: 23 October 2024