A New South Wales coroner has recommended professional reviews for medical staff after 29-year-old Dictor Dongrin died from untreated alcohol withdrawal in Australia's largest prison.
The tragic passing of Dictor Dongrin, a twenty-nine-year-old man, has led to a scathing assessment of medical protocols within the New South Wales correctional system.
Mr. Dongrin died in 2022 while held at the Clarence Correctional Centre, which is recognized as the largest prison in Australia and is managed by the global conglomerate Serco. The circumstances surrounding his death were examined during a coronial inquest led by Deputy State Coroner Rebecca Hosking. The evidence revealed that Mr. Dongrin was suffering from severe alcohol withdrawal, a condition that can be life-threatening if not managed with precision and urgency.
Following a violent incident at his family home in Coffs Harbour involving his father, Moses Dongrin, Dictor was arrested in June 2022. He entered the correctional facility the day after his arrest, and in a devastating turn of events, he was found dead in a medical unit cell by the following afternoon. Coroner Rebecca Hosking determined that the primary cause of death was cardiac arrhythmia brought on by the state of alcohol withdrawal.
The findings highlighted a catastrophic failure in the duty of care provided by the prison medical staff. Despite an initial intake assessment that yielded a score of eight, which should have triggered immediate and serious concern, no appropriate considerations were made to transfer Mr. Dongrin to a hospital for specialized care. The coroner described the treatment provided as wholly inadequate, noting a complete absence of clinical observations between the initial assessment and the discovery of his body.
This negligence suggests that Mr. Dongrin may have been deceased for up to two hours before any resuscitation efforts were even attempted. Barrister Ian Fraser, representing the grieving family, pointed out the cruel irony that a man died in a cell specifically designated for clinical observation while no such observations were actually being performed. He attributed these failures to a system of apathy and a profound lack of professional responsibility among the staff.
In response to these findings, Judge Hosking has recommended that the conduct of two nurses and a specialist doctor overseeing drug and alcohol treatment at the facility be reviewed by their respective professional councils, including the Nursing and Midwifery Council and the Medical Council of NSW. The scale of the Clarence Correctional Centre, which houses up to seventeen hundred inmates, underscores the necessity for rigorous medical oversight.
While legal counsel for Serco, Jillian Caldwell, expressed sincere condolences to the Dongrin family and claimed that various measures have since been implemented, the coroner insisted on further systemic changes. These measures include structured medical shift handovers, daily briefings, and upgraded cell technology.
However, the coroner has gone further by instructing Serco to conduct a comprehensive audit of medical staff knowledge regarding state health guidelines for drug and alcohol treatment. She also emphasized the need for corrections staff to have direct access to the NSW Health single digital patient record to ensure that observations are recorded and monitored in real-time. The human cost of this institutional failure is most poignantly expressed by Dictor's mother, Rebecca Deng.
She shared her heartbreak with the media, stating that her family has been broken by the fact that the prison staff failed to perform their jobs properly. Ms. Deng compared the experience to her home country of Sudan, where she noted that any prisoner who fails a medical check is immediately sent to a hospital. Her testimony serves as a stark reminder of the gap between the expected standard of care and the reality faced by inmates in custody.
The case of Dictor Dongrin now stands as a call for urgent reform in how alcohol withdrawal and general medical emergencies are handled within the Australian prison system to prevent such a preventable loss of life from occurring again
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