Inquest into the death of M A

Contributing factors

• Inadequate assessment of recent heavy methamphetamine use and potential withdrawal effects
• Failure to reinstate escitalopram medication prior to psychiatric assessment
• Placement in single-occupancy cell with known hanging points despite unmedicated state and unassessed mental health
• Insufficient information sharing between health staff and correctional officers regarding mental health risk
• Lack of protective two-person cell placement pending psychiatric review
• Cell architecture containing multiple hanging points
• Brief and superficial initial health screening with low Kessler-10 score failing to capture clinical risk
• Cellmate's departure leaving prisoner alone in unsafe environment

Coroner's recommendations

1. MTC-Broadspectrum should alert its health provider SVHS to consider reviewing induction nursing training regarding the potential mental and mood effects of ceasing amphetamines after heavy use, particularly in inmates with known depression history
2. Formal protocols should be considered to mitigate risk of placing prisoners with documented mental health histories alone in cells known to provide hanging points prior to full mental health assessment
3. Placement of at-risk prisoners in two-out cells should be considered until mental health assessment and medication review is completed
4. Support the recommendation from Magistrate Elizabeth Ryan's inquest into death of L regarding exploration of tear-resistant sheets for inmates in normal cell placement
5. Government commitment and budgetary support is needed to implement comprehensive cell design solutions to eliminate hanging points across the correctional estate, as identified in the Perumal Pedavoli Architects review