Inquest into the death of W

Contributing factors

• Untreated first-episode psychosis with paranoid delusions
• Failure to conduct daily nursing observations as mandated by regulation and policy while in protective custody
• Inadequate clinical handover between mental health nurses on 9 May 2011
• Absence of documented follow-up plan or appointment after initial assessment
• Prolonged isolation in single cell without adequate mental health monitoring
• No psychiatrist available at John Morony Correctional Centre for urgent review
• Delayed access to Mental Health Screening Unit (B-rated, priority 4)
• Lack of awareness by Corrective Services officers of recent RIT assessment and mental health status
• Failure to communicate parole refusal to inmate
• Limited clinical pathways available for acutely mentally ill inmates in custodial settings

Coroner's recommendations

1. When there is a handover of patient care, a note of that handover should be recorded in the patient's case file
2. In the event that there is no opportunity for direct handover from clinician to clinician (e.g. a gap of a day or more), the patient should be recorded on the incoming clinician's Patient Administration System (PAS) waiting list as an appointment, as part of the handover
3. The current Policy 1.360, Continuum of Care, Segregated Custody, be amended to make it clear and unambiguous that it also applies to directions for protective custody
4. There be education of nurses in their obligations under the Justice Health segregated custody policy (applying the current Crimes (Administration of Sentencing) Regulation 2014 clause 289) as to the scope of the duty required, including making a record of the observations, when seeing protective custody inmates
5. That consideration be given to the use of telehealth as an emergency measure for psychiatric review in situations where a psychiatric review is urgently required and a patient cannot be seen face to face, or where staff envisage a prolonged period on the MHSU waitlist before the patient is transferred and admitted
6. Based on the fact that the regulations require Justice Health to monitor inmates subject to protected custody and segregated custody directions, a revision be made of current Corrective Services NSW, Section 14, Segregated and Protective Custody policy at clauses 14.7.4 and 14.7.7 to ensure that the requirement to notify Justice Health of a direction is included
7. Consideration be given to whether a revision should be made to the OIMS system to include notification to Justice Health in the form of an alert (via the Justice Health PAS system) of a protective custody or segregated custody or confinement direction, when it is made
8. Training be conducted at the John Morony Correctional Centre on the specific issue of maintaining and preserving a crime scene and crime scene management generally