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Investigation into the death of a woman following an asthma attack at Nelson custody unit

26 September 2024

The Authority oversaw a Police investigation into the circumstances surrounding a woman’s death. The woman became ill while in Nelson custody unit, and later died in hospital. Her family raised concerns about what had happened.

On Saturday, 16 December 2023, the woman was detained at the Nelson custody unit. She could not be released on bail due to her charges and had to appear before a Judge the following Monday.

Upon arriving at the custody unit, the woman informed the staff that she had asthma but said she did not need an inhaler at that moment. She did not mention that she had been recently hospitalised for asthma.

She later reported feeling short of breath and was given an inhaler from the Police store, which improved her breathing. This inhaler was not the type she customarily used to control her symptoms. The custody staff unsuccessfully tried to contact a nominated friend to ask them to bring in her inhaler. They consulted the on-call doctor, who advised the inhaler she was using would be sufficient.

On Sunday 17 December 2023, at 2:30am, the woman reported having difficulty breathing. Custody staff called an ambulance, but the woman went into respiratory and cardiac arrest. Her heartbeat was restored, and the woman was taken to the Nelson Hospital for continued care. She passed away two days later.

Nelson custody unit has a mould infestation that is treated and managed by an independent contractor. The Police investigation found:

• Insufficient evidence indicating any link between the mould infestation at the Nelson custody unit and the woman's asthma attack. The unit had been treated and decontaminated a week before her custody, and tests showed low mould levels on the day of the incident.

• Custody staff cared appropriately for the woman while she was in Police custody.

The Authority agreed with the outcome of the Police investigation, including the recommendations made.

IPCA: 23-20905

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