Inquest into the Death of Dannielle Stacey LOWE
Inquest into the Death of Dannielle Stacey LOWE
Delivered on : 10 April 2025
Delivered at : Perth
Finding of : Coroner Jenkin
Recommendations : Yes
Recommendation No. 1
The Department of Justice should make it mandatory for all prison nurses and doctors to successfully complete Advance Life Support Course Level 2 (ALS2) or an appropriate alternative course, within six months after their initial employment, and every three years thereafter.
Recommendation No. 2
Given the critical importance of ensuring that all medication issued to prisoners by custodial staff is recorded and can be reviewed daily by nursing staff, the Department of Justice should issue a Commissioner’s Bulletin (or similar) reminding all custodial staff of the importance of strict and ongoing compliance with “COPP 6.4 - Officers issuing medication”.
Recommendation No. 3
For the avoidance of doubt, the Department of Justice should issue an instruction to all nursing and medical staff providing health services at Wandoo Rehabilitation Prison, that where a prisoner makes a written request to be reviewed by a nurse or doctor, the health professional conducting that review ensures that all of the issues referred to by the prisoner in their written request form are addressed, whether raised by the prisoner at the review or not.
Recommendation No. 4
In order to provide culturally safe care to Aboriginal prisoners in Western Australia, the Department of Justice should redouble its efforts to recruit Aboriginal staff at its prisons, including medical officers, nurses, psychologists, social workers, and prisoner support officers. Culturally safe care for Aboriginal prisoners in Western Australia may also be achieved by establishing partnerships with Aboriginal community controlled health organisations and medical services, to provide access to visits from Aboriginal health practitioners, and by developing an Aboriginal Elders visiting program.
Orders/Rules : No
Suppression Order:
On the basis that it would be contrary to the public interest, there be no reporting or publication of the name of any prisoner (other than the deceased) housed at Wandoo Rehabilitation Prison in December 2022. Any such prisoner is to be referred to as “Prisoner [Surname Initial]
Summary : Ms Danielle Stacey Lowe (Ms Lowe) was 41-years of age when she died at Fiona Stanley Hospital (FSH) on 24 December 2022 from complications of intracerebral haemorrhage due to ruptured aneurysm.
Ms Lowe’s medical history included: depression, anxiety, and multiple traumatic injuries related to episodes of domestic and family violence (including fractures to her right leg, fingers and jaw, perforated ear drum, lacerations to the scalp, and closed head injuries).
When she was taken into custody at Greenough Regional Prison on 21 January 2022, Ms Lowe told the reception officer about her history of polysubstance use including cannabis, and methylamphetamine, as well as her history of self-harm, including a previous suicide attempt. Ms Lowe also disclosed that her mother had died from “an aneurysm”.
On 25 March 2022 At the relevant time, Ms Lowe was a sentenced prisoner at the Wandoo Rehabilitation Prison (Wandoo), where she had been transferred at her request.
In December 2022, Ms Lowe began complaining of headaches and had a period of nausea and vomiting. After considering the available evidence (including exert medical evidence), the coroner concluded there had been four missed opportunities in the care and treatment Ms Lowe’s received in relation to her complaints of headache, and vomiting.
The first missed opportunity in Ms Lowe’s care and treatment occurred on 6 December 2022 when Ms Lowe went to the medical centre at Wandoo complaining of the sudden onset of severe headache. Ms Lowe was seen by a nurse and described “high pressure” behind her eyes, and said she had been vomiting constantly “for three hours”. After a brief review by a prison medical officer (who says she was not told about Ms Lowe’s report of constant vomiting) Ms Lowe was given analgesia and anti-nausea medication. Ms Lowe’s condition improved and she was returned to her prison unit.
It appears this incident may have been a “herald bleed” in relation to Ms Lowe’s cerebral aneurysm, and medical experts said that with the benefit of hindsight, Ms Lowe should have been taken to hospital, and a sudden onset severe headache with a history of vomiting was a “red flag” and required investigation.
The second missed opportunity relates to the failure to appreciate the significance of her regular and ongoing requests for Panadol in the period October to December 2022. For unknown reasons, between about November 2022 and March 2023 prison officers at Wandoo were not required to record overnight medications issued to prisoners in a medication log, as they had previously. As a direct result of this decision, the Panadol issued overnight to Ms Lowe by prison officers on various occasions was not recorded, meaning that the reason(s) why Ms Lowe was requiring ongoing analgesia were not explored.
The third missed opportunity occurred on 11 December 2022, when Ms Lowe was seen at the medical centre, having requesting an appointment with a prison nurse the day before for “back pain and headaches”. When reviewed by a nurse, Ms Lowe did not mention her headaches. Although “headaches” were mentioned on the appointment request form, the nurse did not ask Ms Lowe about her headaches, apparently because of a misunderstanding of the therapeutic ethos at Wandoo.
The fourth missed opportunity occurred on 21 December 2022 when at about at about 8.55 am Ms Lowe was brought into the medical centre complaining of “migraine pain”. Ms Lowe described a sudden migraine pain when she bent to pick up a vacuum cleaner. Ms Lowe was given analgesia and returned to her prison unit.
Shortly before 4.00 pm on 21 December 2022, Ms Lowe collapsed in her cell and she was taken to FSH by ambulance. Tests confirmed she had experienced a catastrophic, non-survivable intracerebral haemorrhage, and after an assessment, Ms Lowe was deemed an unsuitable candidate for neurosurgical intervention. Ms Lowe was placed on life support and kept comfortable, and she was declared deceased at 6.27 pm on 24 December 2022.
After assessing the available evidence, the coroner concluded that the management of Ms Lowe’s general health was reasonable. However, on the basis of the missed opportunities identified, the coroner concluded that the management of Ms Lowe’s reports of headaches (and her intermittent episodes of nausea and vomiting) in the period leading up to her death was poor.
The coroner made four recommendations aimed at improving the care and treatment of prisoners in Western Australia.
Catch Words : Death in Custody : Cerebral aneurysm : Missed opportunities : Natural Causes
Last updated: 29 May 2025