Findings into the death of MH

Contributing factors

• Severe chronic treatment-resistant schizophrenia with substance use disorder
• Inadequate psychiatric review and monitoring in custodial setting
• Prioritization of acute presentations over chronic mental illness in prison
• Recent discharge from mental health hospital with unclear transition planning
• Access to razor blades and obvious hanging points in cell despite known self-harm history
• Medication regime change without proper psychiatric assessment
• Lack of therapeutic environment and resources for chronic mental illness in prison
• Reappearance of psychotic symptoms evidenced by cellmate observations
• Distressing family communication and cessation of maternal contact prior to death
• Prison system resource constraints limiting psychiatrist availability

Coroner's recommendations

1. The coroner requested that findings and the 'renewed model' of care be provided to the Ministry of Health for consideration (rather than make a direct recommendation to an external party not involved in proceedings)
2. That consideration be given to developing health care plans for patients at Goulburn Correctional Centre who suffer from chronic and major mental health illness, with such plans being updated as necessary by the care coordinator/case manager and including: diagnosis, medication, cell placement, target frequency of review, early warning signs of deterioration or relapse, target interventions including metabolic monitoring/psychology/employment/psychosocial supports, risk management and recovery plan, and the wishes of the patient and family