Doctor rejects claims he failed to properly examine woman before she died

Warning: This story contains graphic content, and the name and images of a deceased Indigenous person.

A doctor who checked an Indigenous inmate before she was found dead in a prison cell has admitted to making a string of errors, including wrongly recording that Veronica Nelson wasn’t withdrawing from drugs or had any medical history, after coronial investigations uncovered major failings in his paperwork.

Doctor Sean Runacres arrives at the Coroners Court of Victoria to give evidence on Wednesday.Credit: Darrian Traynor

Medical practitioner Sean Runacres – who now works in aviation medicine – was a part-time prison doctor responsible for assessing Nelson when she arrived at the Dame Phyllis Frost Centre on New Year’s Eve 2019.

Speaking at an inquest on Thursday into Nelson’s death in custody, Runacres conceded he’d made numerous errors in his electronic records during the assessment and that those errors had the potential to put patient safety at risk. Those mistakes, he agreed, also meant he’d failed to comply with his professional obligations to take accurate notes.

“I haven’t done that adequately,” Runacres said.

During his evidence, the doctor revealed he had no memory of his interactions with Nelson – including what occurred during her medical assessment on arrival in the prison – but refuted claims from a nurse that he failed to conduct a proper medical assessment at all, labelling his former colleague Stephanie Hills a “liar” who could not be trusted.

Prison records provided to the inquest show Runacres spent 13 minutes assessing Nelson in a medical examination room, shortly before completing his shift, and deemed her to be “generally well”.

In watching CCTV of his first interaction with Nelson, which showed her walking down a prison corridor to the assessment room on December 31, 2019, Runacres replied: “that’s not someone that’s so unwell that I need to do something about it”.

“If someone is able to walk down the corridor and has a blood pressure and heart rate within normal range, I wouldn’t call that extremely unwell,” the doctor said.

The observations followed criticism earlier this week from Hills – a former prison nurse – who recalled Nelson being so unwell she could not sit up in a chair on her own, and was fading in and out of consciousness.

Veronica Nelson, left, is seen walking through prison halfway near doctor Sean Runacres, far right.

Hills, who was inside the examination room alongside Runacres, also claimed the doctor failed to perform basic health checks on Nelson such as heart and lung observations, dismissed questions on whether to take Nelson to hospital, and did not move from his chair during the interaction.

The nurse told the coroner that when she raised serious concerns about Nelson’s presentation, the doctor told her “you’re just a nurse” and “I’m the doctor, I will make the decisions”, before later overriding his decision and keeping Nelson in medical for the night.

On Thursday, Runacres – who no longer works for healthcare provider Correct Care after four years working part-time at the women’s prison – said he had no memory of saying those things.

“I think Ms Hills is a liar,” Runacres said.

Nurse Stephanie Hills outside the Coroners Court of Victoria on Wednesday.Credit: Darrian Traynor

He also said he had no memory of telling a prison officer: “How many prisoners do we see withdrawing. [Nelson] needs to stop asking. We can’t give her anything else.”

Coroner Simon McGregor is investigating Nelson’s death as part of a mandatory five-week long inquest. The coroner earlier heard that Nelson had been arrested on alleged shoplifting and bail offences before being refused bail and remanded in custody at the Dame Phyllis Frost Centre. She was found dead there inside a prison cell on January 2, 2020.

An autopsy later found Nelson weighed 33 kilograms and had the undiagnosed medical condition Wilkie syndrome, which restricts a person’s arteries.

On Thursday, when pressed about his lack of memory about the interactions he had with Nelson, Runacres said this was a conscious decision after previously working as a paramedic for about 10 years.

“I’ve seen more dead people than I care to remember. I make a conscious effort not to remember [my patients] so I can go to sleep most nights,” Runacres said.

“This wasn’t a traumatic event for me, I saw somebody who I thought was unwell who I prescribed medication for and never saw again.”

Nelson was found dead in a prison cell about 36 hours after her interactions with Runacres, after she was moved later from the medical unit into a general population cell in the Yarra Unit late the following day.

Runacres conceded that if he had sent Nelson to hospital, there was a greater possibility that she may have lived.

As part of the inquest, the coroner will explore whether systemic racism and bias, or drug use and associated stigma, may have played a part in the 37-year-old’s treatment by authorities.

Images and audio contained in this story were released to the media with permission from the family. For 24/7 crisis support run by Aboriginal and Torres Strait Islander people, contact 13YARN (13 92 76).