Inquest into the death of R N

Contributing factors

• language barrier not adequately addressed during reception screening
• incomplete initial intake assessment at Amber Laurel with no interpreter used
• mental health assessment conducted without interpreter despite language difficulties
• first time in custody with no previous experience
• isolation from family for 6 days with failed contact attempt due to incorrect phone number
• frequent cell transfers causing disruption
• depressed mood and uncertainty about coping not escalated
• delay in answering cell alarm (14-15 minutes) due to single control room operator
• Kessler 10 screening may not have been effective for non-fluent English speaker

Coroner's recommendations

1. Consideration to be given to developing a policy requirement for inmates detained in custody and housed at Amber Laurel Correctional Centre prior to movement to a reception centre be provided with a personal telephone call to a nominated family member preferably within 24 hours but certainly no later than 48 hours
2. Encourage CSNSW to ensure all Officers engaged in Reception Screening Process undertake online learning module refresher if necessary
3. Conduct audit at Amber Laurel to ensure screening process shortcomings have been addressed since RN's death
4. Review and continuation of policy implementation changes already made by new operators regarding interpreter use, control room staffing, and hanging points identification/removal