Inquest Into The Manner And Cause Of Death Of Mark Robert Watson

Contributing factors

• Failure to conduct proper inspection of unit following attempted hanging on 15 September 1996
• Absence of a key policy allowing immediate access to detained persons' rooms, particularly on night shift
• Failure of five-minute observations to be properly conducted by staff member Ian Barnwell
• Early departure of shift supervisor and observing staff from their posts in breach of proper shift protocols
• Unsafe physical environment - gap between shelf and wall in room 605 allowing ligature point
• Failure to provide detailed written handover concerning suicide risk status
• Inadequate supervision of night shift staff by senior youth worker Daniel Baker
• Inappropriate on-call manager reporting structure bypassing the actual centre manager
• Failure of management to conduct meaningful inquiry into the incident of 15 September
• Lack of comprehensive documentation systems and record-keeping procedures
• Return of vulnerable detainee to previously unsafe unit

Coroner's recommendations

1. Inquiry into problems caused by dynamics of children resident at Quamby, particularly the mix of different categories of residents, including consideration of separate facilities for different age groups and types of detainees
2. Construction of proper facility for young people involved in criminal justice system with mental health or behavioural problems, under proper medical supervision
3. Only one governmental division responsible for all corrections administration in the Territory
4. Change role of Director to ensure the director does not have an active day-to-day management role; manager must manage Quamby and only be overseen in a supervisory way
5. Abolition of on-call duty manager system, replacing it with payment of manager special allowance to be on call at all times, or alternatively ensuring on-call manager reports only to the actual manager
6. Thorough and urgent review of policy and procedure manual to provide proper and complete instructions relating to care and safety
7. Immediate change to policy on availability of keys to workers, particularly night shift staff; keys must be either on person or immediately available without delay
8. Review and change policy relating to access to units by individual workers; single worker must be able to access immediately in emergency situations
9. Policy and procedure manual must contain direct instruction requiring full and complete inspection and search of any unit where self-harm incident has occurred, with detailed report kept on individual's dossier
10. Review of administrative file-keeping procedures to maintain all information about an individual in one file, with clear documentation trail of all actions relating to induction, housing and observations
11. Careful consideration of role of control room log book and special observation book; workers must understand necessity for accurate and honest completion, with clear directions for supervisors to audit these documents
12. Formalised direction in policy manual requiring formal shift handover involving all members of ending and ongoing shifts, with documentary evidence maintained
13. Development of protocol between Mental Health Crisis Team and Quamby to ensure all information obtained is fully communicated to relevant authorities
14. Action under Public Sector Management Act 1994 to dismiss Richard George Young, Daniel Mark Baker, Ian William Barnwell, Dianne Joy Dillon, and Peter Michael Mewburn