MACKANDER Bailey 2019-351386 - REDACTED Findings gicen by Mag Truscott DSC on 15-12-2021 can be published
Deceased
Bailey Mackander
Demographics
20y, male
Date of death
2019-11-07
Finding date
2021-12-15
Cause of death
Multiple injuries from fall from height
AI-generated summary
Bailey Mackander, a 20-year-old Wiradjuri man with substance use disorder and anxiety, disclosed suicidal ideation to a prison psychologist. This led to his placement on a Risk Intervention Team management plan requiring isolation in an assessment cell. The subsequent management exemplified systemic failures: the psychologist conducted an incomplete risk assessment without accessing full mental health records or contacting his supportive mother; the RIT coordinator lacked required training; and Bailey received no psychological support while isolated, causing severe distress and panic attacks. He fabricated illness to escape the cell, attending hospital. During escort back to custody, he impulsively jumped over an 8-metre hospital wall, unaware of the fatal drop. The coroner identified failures in least-restrictive care principles, family communication, mental health escalation, and supervision. Multiple recommendations addressed training, documentation, family engagement, and mental health support in custodial settings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Impulsive escape while in custody
- Inadequate psychological assessment
- Incomplete mental health records review
- Isolation in assessment cell without support
- Failure to provide psychological support while distressed
- Poor Risk Intervention Team review process
- Lack of family engagement and communication
- Substance use disorder and anxiety
- Lack of understanding of environmental hazard (8-metre drop)
Coroner's recommendations
- Require psychologist on RIT review teams or provide telehealth consultation
- RIT coordinators must compile and distribute documentation folders to team members
- Include written reasons for placement decisions and cell type selection
- Provide phone calls to approved support persons when placed on ISP or RIT
- Develop staff training on family communication boundaries and consent
- Document hourly observations of inmates in assessment cells
- Escalate deterioration to Justice Health staff immediately
- Review assessment cells at Kariong and consider transfer to facilities with outdoor access
- Conduct review of assessment cell use and least restrictive care
- Develop guidance document for officers managing distressed inmates in assessment cells
- Establish First Nations elder support resources for inmates on RIT
- Ensure requests to see nurses or psychologists are communicated
- Joint working group between Justice Health and CSNSW for custodial mental health model
- Amend Families Handbook regarding family member contact rights
Full text
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