Inquest into the death of F

Contributing factors

• severe schizoaffective disorder with chronic high suicide risk
• inadequate frequency of psychiatric and nursing reviews in final years
• insufficient custodial mental health resources
• decision to permit unsupervised medication without adequate monitoring
• change to monthly medication dispensing without treating psychiatrist involvement
• counter-therapeutic prison environment
• prolonged incarceration with long prison sentence
• history of medication non-compliance and hoarding
• absence of long-term psychiatric facility for sentenced inmates

Coroner's recommendations

1. That the Justice Health and Forensic Mental Health Network use these findings to advance the position before the NSW Ministry of Health that the renewed model of care be implemented in consultation with Corrective Services NSW.
2. That in relation to patients approved for unsupervised medication, consideration be given to developing a guideline outlining that any alteration to the patient's medication regime in relation to antipsychotic and antidepressant medication be approved by the patient's treating psychiatrist. An alteration includes any modification to the type, dosage or frequency of medication, including any shift from daily to monthly dispensing. Such guideline should be disseminated to JH Network staff and Visiting Medical Officers and incorporated in relevant induction and annual training.