Inquest into the death of LP

Contributing factors

• Non-compliance with 24-hour RIT Management Plan review policy; 48-hour interval implemented instead
• Incomplete RIT assessment on 28 September 2017 due to inmate's emotional distress; no clear protocol for such situations
• Lack of awareness among custody and mental health staff regarding risks of self-harm using meal pack plastic packaging
• High inmate volume at Metropolitan Remand and Reception Centre creating logistical pressures on RIT
• Recent traumatic event (arrest for serious violent crime) increasing suicide risk
• Access to materials (toilet paper, plastic meal packaging) from which airway obstruction fashioned
• No specific training provided to staff on this method of self-harm despite LP housing in assessment cell under high-risk protocols

Coroner's recommendations

1. Consideration be given to implementation or variation of relevant Local Operating Procedures at the Metropolitan Remand and Reception Centre to provide that: (a) the interval for review of inmates subject to a Risk Intervention Team Management Plan and/or housed in an assessment cell is to be no longer than 24 hours; and (b) where a review of an inmate cannot be completed such a review is to be deferred to the following day, with priority to be given to review of the inmate on that subsequent day
2. Consideration be given to amending section 5.3 of the Custodial Operations Policy and Procedures to provide guidance to Risk Intervention Team (RIT) members as to what is to occur if a RIT assessment review is unable to be completed due to an inmate's emotional state, level of aggression, or intoxication due to alcohol or drug use and, as a result, the RIT is unable to determine whether a RIT Discharge Plan is to be completed or a RIT Management Plan is to be developed
3. Consideration be given to the circumstances of the death of LP being used as a case study as part of training and education provided to CSNSW and Justice Health staff to raise awareness regarding the possible risks of self-harm associated with the use of plastic packaging from meal packs (with appropriate anonymization, and conditional upon consent being provided by LP's family and following appropriate consultation with them)