In The Matter Of An Inquest Into The Death Of Ian Glen Bransby At Canberra On 14.2.98

Contributing factors

• inadequate induction assessment due to unavailable custodial history
• insufficient training of induction assessment officers
• lack of access to previous psychiatric and medical records
• lack of structured medical management plan despite identified substance abuse and insomnia
• lack of referral to drug and alcohol professionals
• communication gap: police did not inform remand centre staff of serious new charges
• isolation of detainees in cells for extended periods
• absence of documented follow-up for medical issues
• lack of formal monitoring mechanisms for at-risk detainees
• delay in emergency response due to master key access policy and radio malfunction

Coroner's recommendations

1. No induction assessment should be considered complete until the officer has access to the detainee's custodial history
2. Until induction assessment is completed, detainee must be considered at risk of self harm
3. Consider storing detainee histories in electronic form accessible by induction officers at all times
4. All staff conducting induction assessments receive collective training on the induction instrument and procedural arrangements
5. All detainees presenting with history of illicit drug or excessive alcohol use be referred to specialist alcohol and drug professional on induction
6. Install alarm system in each yard of the Remand Centre to notify Control Room of emergencies requiring cell access, as backup to radio systems