Disgraced teacher's death wish?
A DISGRACED former teacher jailed over possessing child abuse and bestiality images refused to take most medications for weeks before his death.
Whether jailers did enough to save Kenneth Douglas Wright will now be for a coroner to decide.
An inquest on Monday discussed Wright's death at a Gatton prison.
The 71 year-old from Rubyvale died six months after falling from a Capricornia jail balcony in an apparent suicide attempt.
It is mandatory in Queensland to have an inquest after deaths in custody.
A doctor told Brisbane Coroners Court she initially believed Wright was not under observation for 15 minutes.
But a timeline now suggested he was not under observation for an hour or more.
"Mr Wright was a very complex patient and also a very challenging patient," Dr Natalie MacCormick said.
"And his condition over the months leading up to his death was deteriorating."
He had chronic pain and underlying cardiac issues.
"To compound that ... he was often refusing medication," she added.
Dan Bartlett, counsel assisting the coroner, asked if Wright's death was "imminent".
"It wasn't expected to occur that day," Dr MacCormick said.
"But he certainly had a high risk of an event occurring that would be fatal."
The inquest heard Wright's vital signs were taken around 1.30pm the day he died in March 2015.
A "Code Blue" emergency was activated about 70 minutes later.
Wright had been wheezing and his blood oxygen saturation was about 77 per cent.
Anything less than 90 per cent required "immediate action", Dr MacCormick said.
She said resuscitation efforts on Wright perhaps could have started earlier.
A forensic pathologist found Wright died from pneumonia due to, or as a consequence of, traumatic brain injury.
"At the time I was very shaken. It was my first death," a prison nurse told the inquest about seeing Wright dead.
She said Wright refused virtually all medication for weeks, except for some pain relief.
Procedures around note-taking, calling ambulances, staff training and the role of public guardians were also discussed.
Mark Walters, a director from private jail company Serco, said the firm had since made changes around detecting deterioration in patients.
Mr Walters said Serco had reviewed equipment in the facility where Wright had been staying.
The inquest continues. -NewsRegional