Inquest into the death of AJ (name redacted)
Demographics
19y, male
Date of death
2013-05-17
Finding date
2015-08-11
Cause of death
hanging
AI-generated summary
A 19-year-old male inmate with schizophrenia died by hanging at Long Bay Correctional Centre. Critical failures in mental health care contributed to preventability: despite initial referral in February 2013, he was never seen by the Mental Health Team in three months of custody due to interrupted transfers between facilities. Guidelines requiring follow-up of patients missing antipsychotic medications were not implemented—he missed seven medication collections without contact from staff or psychiatry. No treating psychiatrist was assigned, medication appropriateness was never assessed, and Corrective Services were not notified of non-compliance. While no evidence suggests missed medication directly caused his suicide, the systemic failures in mental health management, communication between services, and failure to reschedule appointments after transfers created a dangerous gap in care for a vulnerable young person.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to reschedule mental health appointments following transfer between correctional centres
- patient never seen by mental health team despite referral in February 2013
- no treating psychiatrist assigned despite antipsychotic medication prescription
- non-compliance with Justice Health medication guidelines regarding follow-up of patients missing antipsychotic medications
- lack of communication between Justice Health and Corrective Services regarding medication non-attendance
- no follow-up or education provided when patient missed seven medication collections
- medication appropriateness never assessed
Coroner's recommendations
- Justice Health should review practices and procedures for transfer of inmates between correctional centres to ensure outstanding mental health reviews or appointments are rescheduled at the new facility
- The Drugs and Therapeutic Committee of Justice Health and Forensic Mental Health Network should review procedures outlined in section 6.6.1 of the Medication Guidelines
- Justice Health staff should receive training regarding requirements of sections 6.6.1 and 7.7.3 of the Medication Guidelines
- Justice Health should review communication procedures between Justice Health and Corrective Services regarding inmate non-attendance for antipsychotic medication
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