Inquest into the death of Bailey Mackander

Contributing factors

• Placement on Risk Intervention Team without adequate mental health support
• Confinement in assessment cell with 24/7 lighting and no access to open air
• Deprivation of diversionary activities including human contact and phone calls
• Defective RIT review process with untrained co-ordinator
• Senior correctional officers overriding RIT review team decisions
• Lack of psychological intervention during cell confinement
• Inadequate documentation of inmate distress on cell intercoms
• Blocked family contact attempts
• Panic attacks triggered by cell confinement
• Escape from custody while under restraints
• Impulsive action without awareness of 8-metre wall drop
• Escort officer failed to maintain physical restraint during hospital discharge

Coroner's recommendations

1. CSNSW amend RIT policy to require a psychologist or consultation with mental health provider as part of RIT review team
2. CSNSW compile and distribute folder of specified documents to RIT members prior to review meeting
3. CSNSW require written reasons in ISP/RIT plans for placement decisions and cell placement choices
4. CSNSW identify responsible manager/s for inmate management on each shift in RIT plans
5. CSNSW provide opportunity for phone calls: at ISP placement, at RIT establishment/24-hour extensions, and at discharge
6. CSNSW inform inmates of decision, reasons, review timeline, entitlement to phone calls, and consent options for third-party communication
7. CSNSW require RIT members to sign training acknowledgements and record meeting times
8. CSNSW amend RIT forms to incorporate time stamps and signatures
9. CSNSW investigate implementation of third-party support via videoconference at RIT review meetings
10. CSNSW investigate and establish list of First Nations elders/organisations for mentorship support to RIT inmates
11. CSNSW amend policy to communicate inmate requests to see nurse/psychologist/psychiatrist and offer 1800 Mental Health Helpline access
12. CSNSW require hourly documentation in OIMS of observations of inmate behaviour/deterioration in assessment cells
13. CSNSW require staff to contact Justice Health if inmate health deteriorates in assessment cell
14. CSNSW address assessment cells at Kariong TIC - ensure fit for purpose with access to daily exercise or transfer to appropriate centre
15. CSNSW conduct review into use of assessment cells for self-harm management and consistency with least restrictive care
16. CSNSW develop guidance document for officers monitoring inmates on RIT in assessment cells
17. CSNSW develop training module and guidelines for staff on communication with family members
18. CSNSW amend Family Handbook to inform families they can provide medical/mental health information in urgent circumstances
19. CSNSW send memorandum reminding staff that family phone calls with health information should be accepted and actioned
20. Justice Health and CSNSW ensure websites and Families Handbook consistent regarding family contact for health information
21. Justice Health and CSNSW convene joint working group to improve custodial mental health model of care
22. Justice Health introduce policy for consent to communicate with third parties during ISP/RIT
23. Justice Health provide Mental Health Helpline phone number to patients on ISP/RIT
24. Justice Health staff receive training on effective communication with families, confidentiality boundaries, and consent processes
25. Justice Health develop protocol to ensure mental health nurses participate in RIT reviews when available
26. Justice Health implement priority referral system for mental health referrals in RIT Management Plans
27. Justice Health seek legal advice on revokable enduring consent for information sharing in custody
28. CSNSW and Justice Health notify each other when Mandatory Notification/ISP created and Justice Health nurse attends inmate
29. Central Coast LHD and Justice Health circulate 'Who is JHFMHN' poster to NSW Health Emergency Departments