Inquest into the death of Fenika Junior Tautuliu Fenika (Junior Fenika)
Deceased
Fenika Junior Tautuliu Fenika
Demographics
24y, male
Date of death
2015-09-12
Finding date
2018-07-13
Cause of death
Massive blood loss caused by incised wounds of left upper extremity
AI-generated summary
A 24-year-old man with schizophrenia and psychotic symptoms died from massive blood loss after self-inflicted wrist lacerations in prison custody. He called for help twice via the cell alarm system at 9:17pm and 9:23pm, but correctional officers failed to respond appropriately. The control room officer misheard both calls, failed to use the reverse knock-up system to clarify, and did not alert the night senior. The rovers attended but did not attempt to reverse knock-up the cell or visually inspect it properly. Blood continued flowing from the cell for hours, visible in security footage but unnoticed. Medical attention in the critical window from 9:17pm to 2:00am would likely have been life-saving. Key failures included inadequate communication protocols, poor knock-up system audio quality, failure of rovers to conduct proper cell checks, and systemic under-resourcing of mental health services in correctional facilities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure to respond appropriately to intercom calls for help
- Control room officer failed to use reverse knock-up to clarify unclear calls
- Poor audio quality of knock-up system
- Rovers failed to visually inspect cell or attempt reverse knock-up
- Systemic isolation and sensory deprivation exacerbating psychosis
- Inadequate mental health assessment and treatment access
- High-risk inmates excluded from mental health screening unit due to security concerns
- Insufficient mental health beds in correctional system
- Medication non-compliance and lack of supervised administration
- Immigration detention status creating additional psychological stress
- Access to razor blades not restricted despite recent self-harm risk assessment
Coroner's recommendations
- Undertake review to determine adequacy of mental health beds for NSW correctional system and provide additional beds for inpatient, step-down and low acuity care
- Improve audio-quality of the Knock-up System at HRMCC
- Amend Local Operating Procedures to require reverse knock-up when calls are unclear
- Require recording of all knock-up calls, actions taken, and officers involved
- Provide regular training on COPP and Local Operating Procedures for all officers
- Rovers to conduct visual welfare checks of cells at least once per watch and provide security support as necessary
- Rovers to inspect rear yards and report anything unusual including blood or water to Night Senior
- Formal consultation with Justice Health mental health nurse regarding razor and sharps access for inmates with recent self-harm or RIT supervision
- Provide sufficient security support to allow transfer of HRMCC inmates to Mental Health Screening Unit for mental health treatment
- Streamline process for approving family visits at HRMCC
- Ensure Justice Health receive real-time information about isolated inmates, appropriate access to isolated inmates, and telehealth facilities
- Amend Justice Health Policy 1.360 to apply to isolated inmates with mental illness
- Establish process for treating psychiatrist to formally notify General Manager when isolation adversely affects patient mental health
Full text
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