![Peter Gretton outside Albury court before being jailed in 2018. File photo Peter Gretton outside Albury court before being jailed in 2018. File photo](/images/transform/v1/crop/frm/u2TKvX7hYXGMrKgrD4ZiFN/8a043bca-ecdd-4ccb-8654-608296a3bbf2.jpg/r0_0_4896_3264_w1200_h678_fmax.jpg)
A coroner has called for changes in the prison system following the death of a Border man in custody.
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Peter Gretton was serving a term at Junee jail after stealing $3.1 million from his employer.
Gretton had stolen from the Jones Group, which runs hotels in Albury and Wangaratta, for 12 years.
The Thurgoona man, 60, died on January 2, 2019 after being taken from the prison to Wagga hospital.
He had awoken about 2am on the day he died and complained of pain before being seen by nurse Loice Maganzi.
It took hours for the nurse to call an ambulance.
![Peter Gretton outside Albury court before being jailed in 2018. File photo Peter Gretton outside Albury court before being jailed in 2018. File photo](/images/transform/v1/crop/frm/u2TKvX7hYXGMrKgrD4ZiFN/628c86ac-0594-44b6-b6a2-67155c38925c.jpg/r0_0_4896_3264_w1200_h678_fmax.jpg)
The 60-year-old had suffered renal failure and went into cardiac arrest while being transported to hospital.
He died about 7pm that night after suffering a heart attack.
While Gretton died of natural causes, deputy state coroner Derek Lee investigated the medical treatment he received while in custody during an inquest.
The coroner found shortcomings in the treatment provided while behind bars, including by Ms Maganzi.
He said her evidence showed she did not correctly identify Gretton's respiratory rate, did not start recording observations until 35 minutes after he arrived for treatment, did not complete proper documentation, and did not follow hypoglycemia guidelines and chest pain guidelines.
It was noted she was "deeply upset and regretted what had occurred on 2 January 2019".
Ms Maganzi no longer works as a nurse or in health care.
A professor said an on-call doctor should have been notified and an ambulance called when Gretton's condition became apparent.
"I don't think doing lots and lots of observations is the point," Professor Anthony Brown said.
"I think number one, call the doctor, number two, call the ambulance, that's the only trigger that should have happened."
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Professor Kate Wyburn gave evidence about Gretton's worsening renal function and said "unfortunately, in many cases, it's very silent until really there is very little kidney function remaining".
Professor Wyburn said the late man's renal impairment had likely occurred in the three to four weeks before his death.
The coroner found it was unlikely Gretton would have survived his condition even if he had made it to hospital before going into cardiac arrest.
But Mr Lee recommended the managing director of the GEO Group, which runs Junee jail, conduct an audit of patients presenting at the prison to ensure vital signs are being taken in accordance with policy.
The coroner also recommended pathology requests are reviewed weekly to ensure results are received in a timely manner, and that medical staff are trained to escalate care when vital signs reach a concerning level.
The cause of Gretton's renal failure was unable to be determined.
The coroner sent his condolences to the late man's family.
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