COI to look into inmate who died from medication

SINGAPORE - The Ministry of Home Affairs has convened a Committee of Inquiry (COI) to look into the facts and circumstances regarding how an inmate died at Changi Women's Prison.

The COI will take into account the findings of a coroner's inquiry, which concluded on Monday that gaps in the prison system played a part in the death of Lian Huizuan, 27.

The probe will be conducted with a view to recommending improvements to systems and processes, the Singapore Prison Service said in a statement yesterday.

Lian died on March 2, 2011, due to toxicity from drugs she was taking for depression, in the presence of a chronic hepatitis C infection.

She had been treated with amitriptyline, chlorpromazine and valproate prescribed by a psychiatrist from the prison's medical provider, Raffles Medical Group (RMG).

The mother of two, who was about a month away from completing her detention order for drug abuse, died after complaining of aching legs during a drill session.

She was seen climbing at an unusually slow pace up the stairs to her cell after the drill. When prison staff tried to give her water, she was unable to drink. A nurse could hardly detect her pulse. She was taken to Changi General Hospital, where she was pronounced dead.

State coroner Janet Wang said on Monday that the prison's doctor and psychiatrist at the time, both from RMG, should have been mindful of the victim's pre-existing medical conditions and the effects of medicines prescribed.

Previously, the court heard that RMG nurses failed to meet requirements set by Changi Women's Prison to record all dispensation of medication into the jail's prescription chart.

Coroner Wang also noted that the inmates were overseen by a "markedly small" number of medical staff over "markedly short periods of time". For example, the psychiatrist visited patients once a week, and for about four minutes on average each time.

She added that there was no review done on whether Lian was fit for drills after she was hospitalised for a week in 2010.

The three members of the COI have been appointed by Minister of Home Affairs Teo Chee Hean. They are Dr Benjamin Koh Khay Wee, director of ComCare and social support from the Ministry of Social and Family Development; Colonel Tan Kan Whye from the Singapore Armed Forces; and Ms Seah Jiak Choo, a retired director- general of education.

A spokesman for the Singapore Prison Service said: "Prisons views the matter seriously. We will study the findings of the coroner and consider all the recommendations made."

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