Watchhouse deaths highlight care gap

Nurses or paramedics should be available 24-7 in all Queensland watchhouses, the Deputy State Coroner has recommended, after an inquest into the deaths of two female prisoners.

In the Coroners Court on Thursday, Deputy Coroner Stephanie Gallager found that although Queensland women Vlasta Wylucki and Shiralee Deanne Tilberoo died of natural causes in detention, they were not adequately supervised and did not receive appropriate medical care.

Ms Wylucki, 50, died in the Southport Watchhouse (SPWH) in March 2018 after being arrested for breaching a Domestic Violence Order. Her cause of death was determined to be ischaemic heart disease due to coronary atherosclerosis.

Ms Tilberoo, 49, died in the Brisbane City Watchhouse (BCWH) in September 2020, after being arrested on four outstanding warrants. Her cause of death was determined to be a subarachnoid haemorrhage, due to a ruptured berry aneurysm.

Deputy Coroner Gallager considered the matters together because the issue of proper care and supervision of inmates by watchhouse officers arose in each case.

“In each case, checks were conducted by WH (watchhouse) officers which recorded that there were “no problems detected” when, in fact, the women appeared clearly unwell or their state of wellbeing could not be properly discerned,” she said.


“In addition, both women were experiencing some level of substance withdrawal, and the management of their symptoms, as well as other pre-existing health conditions, was an issue to be considered by the court.”

She said Ms Wylucki was likely to have been suffering from alcohol withdrawal during her time in custody and there were questions as to whether she should have been given heart medication.

She said Ms Tilberoo was suffering from heroin withdrawal and appeared to remain in the watchhouse for an “unusually long period” of four days, with there being a “a period of some eight hours overnight during which it is likely she had passed away and WH officers did not identify any problems”.

At the time of the deaths, healthcare in the two watchhouses was provided by registered nurses on day shifts, eight hours a day, seven days a week. Statewide, mental health nurses visited watchhouses on weekdays, and support was provided to nurses and watchhouse staff by on-call doctors.

Deputy Coroner Gallagher said the absence of 24-hour, seven-day nursing services was “a systemic issue which is applicable to all prisoners in WHs in Queensland”.

She found that Ms Wylucki, “as a prisoner with specific medical needs, may have been disadvantaged simply because she was admitted to the WH after usual business hours”.


“I find that Ms Wylucki’s death may have been prevented if there was more consistent provision of medical services in the SPWH,” she said.

“Had a nurse been on site at the time of Ms Wylucki’s admission, there would have been an opportunity for Ms Wylucki to have had a medical assessment before she was taken to the cells.

“She could have been encouraged to continue her prescribed medication regime and her prescribed medication (or other appropriate medication) could have been dispensed to her that evening. The effects of her alcohol intake could have been assessed properly.”

Deputy Coroner Gallagher said “an important opportunity for a patient with clear medical needs to be given medical attention” was missed.

“This opportunity should not be dependent upon the time at which a prisoner is admitted – the legislated obligation of the QPS (Queensland Police Service) to care for the health and safety of persons in WHs is not confined to business hours.

“Similarly, had a nurse been on site when Ms Wylucki was vomiting in her cell, and assuming checks had been properly done so that this situation was known to WOs (watchhouse officers), a nurse could have made an immediate assessment of Ms Wylucki’s condition and may have had an opportunity to provide life-saving resuscitative treatment.


“As has been made clear in the evidence during inquest, in the absence of nurses, non-medically trained WH staff must make these clinical assessments of prisoners, and then delays, while medical assistance is sought … are inherent in the system.”

Deputy Coroner Gallagher found Ms Tilberoo was at a similar disadvantage to Ms Wylucki.

“Had Ms Tilberoo had an assessment with a nurse upon her admission, she may have been encouraged to have disclosed her heroin withdrawal and have been provided with appropriate treatment for her withdrawal signs and symptoms at an earlier time,” she said.

“Ms Tilberoo’s circumstances draws attention to another systemic issue within the WH setting: the inability for WH prisoners who are experiencing drug or alcohol withdrawal to access OTPs (Opioid Treatment Programs) because of the assumption of short-term custody in the WH.

“This issue is exacerbated when wait times for transfers into QCS (Queensland Corrective Services) custody, where appropriate treatment is more readily available, are extended.”

In one of four recommendations, Deputy Coroner Gallagher suggested the Queensland Government provide additional resourcing to Queensland Health for it to place nursing and/or paramedical clinicians in all WHs, in person or by using technology, around the clock.


She recommended subsequent to that, QPS amend its Operational Procedures Manual to provide that the initial health assessment of a WH prisoner is conducted by a Queensland Health clinician.

She also recommended the Corrective Services Act 2006 (Qld) be amended to reduce the time a person may be detained in a watchhouse from 21 days to 72 hours, and that QPS be resourced to provide more training of watchhouse officers.

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