Inquest Into The Circumstances Surrounding The Death Of Shannon Robert Camden

Contributing factors

• Failure to conduct required 30-minute observations
• Failure to conduct 15-minute observations of other detainees that would have required presence in yard
• Inadequate supervision by shift supervisor
• Failure to implement proper management protocols
• Facility design inadequacies
• Lack of psychiatric nursing support
• Lack of coordination between external mental health services and remand centre
• Delay in Mental Health Tribunal proceedings and assessments
• Change from 15-minute to 30-minute observations without documented rationale
• Failure to properly utilize Special Care Unit
• Lack of medical officer appointment as required by statute
• Absence of coordinated case management for mentally unwell detainee
• Decommissioning of Special Care Unit nursing and supervisory staff

Coroner's recommendations

1. Prosecutions against John Michael Kelly, Bradley John Gordon, and Gavin Curbishley for perjury and attempt to pervert the course of justice
2. Prosecution against Edward Grahame MacKenzie for attempt to pervert the course of justice and consideration of perjury charges
3. Dismissal from Public Service of MacKenzie, Kelly, Gordon, and Curbishley
4. Consideration of termination of employment of Arnoldus Marinus Joseph Van Hinthum
5. Establishment of Corrections Health Board as matter of urgency
6. Provision of adequate resources to mental health services for speedy assessments by Mental Health Tribunal
7. Construction of new appropriate remand facility
8. Complete external review of Belconnen Remand Centre operations
9. Construction of proper mental health facility for detainees with mental health or behavioural problems (preferably attached to Canberra Hospital)
10. Acquisition and installation of Automatic Guard Tour System for observations
11. Superintendent to have access to all medical, correctional and welfare files relating to detainees
12. Development of procedures for medical officer to access available medical information relating to detainees
13. Development of protocols between BRC and all external agencies providing support
14. Appointment of case managers by mental health service for people with mental dysfunction in custody
15. Interagency protocols to provide access to relevant information with consent
16. Mental Health Tribunal to receive thorough investigative assessments not just diagnostic assessments
17. Government to accept and implement responsibility to provide necessary resources for safe custody
18. Ensure Magistrates making MHT referrals arrange immediate advice to Office of Community Advocate
19. MHT assessment requests be specific about questions and advice be clear about limitations
20. MHT not rely on same service/professional for both assessment and involuntary treatment
21. Changes to Mental Health Tribunal composition to avoid conflict of interest (magistrate should not preside over MHT while involved in criminal proceedings with same respondent)
22. More careful preparation of applications before Mental Health Tribunal
23. Consideration of impact of staffing shortages on detainee welfare and family contact
24. Reactivation or proper operation of Special Care Unit
25. Understanding by outside agencies of urgent nature of detainee support needs
26. Appointment of full-time medical officer under Remand Centres Act
27. Clear procedures for officer responsibilities and outside agency contact
28. End to ad hoc documentation system at BRC
29. Implementation of procedures ensuring information reaches relevant officers promptly with proof
30. Feedback to officers on action taken regarding their reports
31. Documentation of superintendent consultations and decisions on detainee movements
32. Appointment of vigorous and robust superintendent to implement changes