(This summary was written with a lot of help from teachers.
Sorry but, actually I have no English skill, so maybe I can’t answer, even if you reply to me.
Please check the final report files and newspaper articles.)
[Summary of memos vol.9]
The final report files P.72
「The operation was such that the bureau executives were not responsible for making decisions such as the application form, understanding the facts, and the need for medical treatment.」
And I feel strange about the following contents.
The final report files P.78
「The judgment would have been difficult for them, especially if they had realized that it is effect of medicine prescribed on the March 4th.」
「They should have responded promptly.
But immediate action was difficult for them if the prison guard thought that it was effect of medicine prescribed on the March 4th.」
The final report files P.48
「March 5th (Friday)
The prison guard and other staff recognized that it was effect of medicine prescribed on the March 4th, they didn't think it was her life-threatening factor.」
Did the staff think that Quetiapine made her lose consciousness?
Did the workers somehow detect the effect and side effects of medicine?
Did they read the Inmate’s medication status?
Did they have a chance to share information about the effects and side effects of medicine?