Inquest Into The Death Of Tania Pauline Lioulios Nee Chacos

Contributing factors

• failure of Mental Health ACT to notify Court Liaison Officer of multiple presentations in 18 hours
• inadequate assessment and risk stratification by Mental Health ACT despite clear suicidal ideation
• failure to escalate to psychiatric registrar despite two assessments in 24 hours
• inadequate handover of information between Australian Federal Police and Corrective Services regarding suicidal threats
• failure to include mental health clinical notes in prisoner file
• use of unsuitable transport vehicle without surveillance capacity
• lack of appropriate observation protocol during transport
• four and half hour delay between court remand and transfer to Belconnen Remand Centre
• failure to access Court Liaison Officer services
• ambiguous Standing Order 20 regarding classification and procedures for prisoners at risk
• failure of Mental Health ACT staff to assess patient on multiple occasions adequately

Coroner's recommendations

1. Where a person in custody presents for mental health assessment more than once in 24 hours, the patient must be seen by a psychiatric registrar
2. Mental Health ACT must notify the Court Liaison Officer when a person assessed by Mental Health ACT is scheduled to appear in court through a compulsory field on computerized records
3. The role of the Court Liaison Officer should be brought to the attention of AFP, legal profession, DPP, Correctives and Court officers
4. The Prisoner Alert Sheet should be signed by both AFP officer and Correctives officer at handover
5. Handover procedures should be recorded in police cells
6. Persons whose files are marked Prisoner At Risk should be afforded access to Court Liaison Officer as soon as practicable after transfer from police cells
7. Priority should be given to preparation and execution of detention warrants for persons marked At Risk
8. Agencies involved should meet regularly to review and revise agreed protocols and procedures
9. Ongoing training and supervision must be part of the process to eliminate complacency and deviation from procedures
10. All vehicles used to transport prisoners must have CCTV, lighting and intercom systems
11. Prisoners at high risk should be transported in station wagons with officers seated on either side
12. A Monitor Officer should be stationed in court cells to continually monitor remanded prisoners
13. Priority should be given to removal of prisoners at risk from court cells
14. Mental Health ACT record keeping should be modified to ensure notification of Court Liaison Officer