Inquest into the death of A

Contributing factors

• inadequate mental health staffing and waitlist delays
• failure of mental health nurse to assess patient despite referral
• insufficient inter-agency communication regarding mental health referrals
• lack of communication between family and correctional authorities about mental health concerns
• failure to conduct comprehensive risk assessment when suicidal ideation was expressed
• access to hanging materials and hanging points in cell
• immigration visa cancellation causing distress
• relationship breakdown in final week
• death of uncle in final days
• therapeutic environment design that prioritized amenity over suicide mitigation

Coroner's recommendations

1. That consideration be given to reviewing Custodial Operations Policy and Procedures 3.7, including annexures 'Risk Factors for Consideration - Reference Guide' and 'Inmate Interview Questions' to determine whether the Policy should apply to psychologists and other professional mental health practitioners employed by CSNSW; and determine whether the matters referred to in the Risk Factors and Inmate Interview Questions documents currently meet the criteria for best practice to prevent suicide or self-harm of inmates. This review should also consider whether an additional risk factor be listed, namely the potential risk for self-harm posed by the inmate's current accommodation.
2. That CSNSW and the Justice Health and Forensic Mental Health Network develop the necessary procedures and policies to ensure that referrals made by the JH Network for mental health services for inmates and the outcome of those referrals be communicated to CSNSW psychologists.
3. That CSNSW and the Justice Health and Forensic Mental Health Network develop compatible policies and procedures to ensure that family members of inmates are able to effectively communicate their concerns about the mental health or risk of self-harm/suicide of that inmate.
4. That the Ministry of Health consider the issue of funding for mental health services in Long Bay Correctional Centre, with emphasis on funding for mental health nurse positions.