Inquest into the death of Ye Chiu

Contributing factors

• suicide by deliberate fall
• history of suicidal ideation and psychiatric illness
• hyponatraemia
• anxiety and depression
• vulnerability as elderly first-time prisoner with limited English
• language barriers preventing effective communication
• delay in family notification after hospitalisation
• discharge to general prison population without appropriate support systems
• previous psychiatric admissions not fully communicated to custodial staff

Coroner's recommendations

1. CSNSW amend their policies to ensure that when a prisoner is subject to a medical emergency requiring conveyance to hospital: (a) The prisoner's Emergency Contact Person (ECP) is recorded on the escort and transfer documents; (b) The Escort Officer (or another identified appropriate officer) ensures that the ECP information is transferred to the hospital triage document so the hospital has the prisoner's ECP details; (c) A CSNSW staff member is identified and allocated the responsibility of: (i) identifying the health status of the prisoner on a regular and frequent basis to enable a decision to be made that the prisoner's ECP be informed of the prisoner's condition; (ii) managing and facilitating the visiting access the ECP has to the prisoner with the Escort Officers; and (iii) managing updating the ECP as to the condition of the prisoner
2. An audit of the policy should occur within a reasonable period of time of the commencement of such policy to ensure that it is being complied with and is consistent with any Memorandum of Understanding between CSNSW, Justice Health and Forensic Mental Health Network and the Ministry of Health NSW