Inquest into the death of Glen Russell

Contributing factors

• inadequate intake screening and assessment for suicide risk
• incomplete recording of self-harm history and recent self-harm episodes in screening documents
• failure to communicate collateral information from community support worker to custody staff
• inappropriate mental health assessment priority rating (level 5 instead of 1-2)
• failure to obtain GP records for medication verification in timely manner
• delayed commencement of psychotropic medications in custody
• consolidation of self-harm and suicide questions in screening tools preventing distinction between concepts
• lack of training in mental health assessment for correctional and welfare staff
• staffing shortages in Justice Health nursing
• inadequate mental health monitoring in prison general population
• separation from de facto partner and breakdown of family relationships
• incarceration while experiencing multiple stressors

Coroner's recommendations

1. Justice Health: Amend Reception Screening Assessment form to mandate recording of answers to clarifying follow-up questions when patient answers 'yes' to mandatory suicide risk assessment questions
2. Justice Health: Clarify Patient Administration System appointment priority rating categories 1-5 specifically as they apply to mental health assessments
3. Corrective Services: Clarify in Operations Procedures Manual the interaction between safety/security requirements for opening cells in response to cell alarm in maximum security and duties of first responding officer in potential death in custody
4. Corrective Services: Separate consolidated questions in Intake Screening Questionnaire concerning self-harm and suicide into four discrete questions (current plans to hurt yourself, current plans to end your life, previous self-harm attempts, previous suicide attempts)
5. Corrective Services: Amend consolidated question in Reception Checklist regarding 'current thoughts of self-harm/suicide' into two discrete questions (current thoughts of self-harm, current thoughts of suicide)
6. Corrective Services: Clarify policy on distribution of mail to inmates subject to ADVOs to ensure consistent approach
7. Corrective Services: Conduct scenario-based training with officers on responding to potential deaths in custody and crime scene management
8. Corrective Services: Develop procedures for recording and disseminating collateral information about inmates from external sources such as family members or support workers
9. Corrective Services: Provide mental health training to staff conducting screening, including clarification that screening phone calls are for obtaining collateral information not just family contact
10. Corrective Services: Ensure 911 Rescue Tools are carried by required staff and provide training in their use
11. Justice Health: Review and clarify that 'current presentation' in mental health assessment should include information from previous weeks before incarceration, not just day-of-assessment presentation
12. Justice Health: Review processes and staffing particularly at Cessnock Correctional Centre in context of increased inmate population