Inquest Into The Death Of Tania Pauline Lioulios Nee Chacos
Deceased
Tania Pauline Lioulios
Demographics
42y, female
Date of death
2008-07-12
Finding date
2009-03-27
Cause of death
Hypoxic ischemic encephalopathy with antecedent cause being self-caused near miss hanging in the rear of an ACT Corrective Services vehicle whilst being transported in custody
AI-generated summary
Tania Pauline Lioulios, a 42-year-old psychologist, died from hypoxic ischemic encephalopathy following a self-inflicted hanging in a Corrective Services transport vehicle on 4 July 2008. She had presented to mental health services three times in 18 hours with suicidal ideation but was assessed as low-risk and released. Critical failings included: inadequate handover of mental health information between agencies; the Mental Health ACT failure to notify the Court Liaison Officer; lack of psychiatric assessment before transport despite clear warning signs; and the use of an unsuitable transport vehicle without surveillance. The coroner found the cumulative effect of systemic failures contributed to her death, emphasizing failures in communication, risk assessment, and observation protocols across multiple agencies including Mental Health ACT, Australian Federal Police, and ACT Corrective Services.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
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
- 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
- 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
- The role of the Court Liaison Officer should be brought to the attention of AFP, legal profession, DPP, Correctives and Court officers
- The Prisoner Alert Sheet should be signed by both AFP officer and Correctives officer at handover
- Handover procedures should be recorded in police cells
- 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
- Priority should be given to preparation and execution of detention warrants for persons marked At Risk
- Agencies involved should meet regularly to review and revise agreed protocols and procedures
- Ongoing training and supervision must be part of the process to eliminate complacency and deviation from procedures
- All vehicles used to transport prisoners must have CCTV, lighting and intercom systems
- Prisoners at high risk should be transported in station wagons with officers seated on either side
- A Monitor Officer should be stationed in court cells to continually monitor remanded prisoners
- Priority should be given to removal of prisoners at risk from court cells
- Mental Health ACT record keeping should be modified to ensure notification of Court Liaison Officer
Full text
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