Inquest into the death of Kevin BUGMY

Contributing factors

• Failure to review and escalate abnormal ECG result from 30 June 2018 showing previous anterior myocardial infarction
• Chronic inhalant use disorder not treated as health issue requiring coordinated therapeutic management
• Placement in employment location providing access to solvents despite known history of inhalant use
• Ineffective alert system in Offender Integrated Management System failing to communicate relevant medical information
• Excessive inter-correctional centre transfers (50+ moves in 19 years) disrupting continuity of health care
• Lack of Aboriginal-specific drug and alcohol programs with culturally appropriate content
• Fragmented service provision between correctional services and health services
• Inadequate case management and support for chronic substance use disorder
• ECG rebooked for 2 years without medical review of abnormal result
• Reception screening tool not updated upon transfer to document recent solvent use incident
• Loss of hope and acceptance that release was not possible after repeated parole refusals

Coroner's recommendations

1. CSNSW introduce a system or process allowing staff assessing inmate suitability for employment in business units to determine from a single, readily accessible, comprehensive source whether any health or medical issue might impede allocation to a particular business unit, incorporating state-wide health alerts across correctional centres
2. CSNSW adopt a policy, procedure or guideline guiding staff assessing inmate suitability for employment in business units about the system or process they should follow
3. CSNSW review its policies, procedures or guidelines applying to inter-correctional centre prisoner movements with a view to reducing prisoner movements in the system, considering the impact of movements on continuity of health and care, and specifically considering the rights of long-term prisoners
4. CSNSW introduce a system or process to monitor the number of inter-correctional centre prisoner movements an individual inmate has undergone to avoid excessive transfers, which may be inhumane and for Aboriginal inmates may exacerbate social and family dislocation, health issues and cultural disconnection
5. CSNSW conduct and evaluate a pilot or trial of an Aboriginal-specific drug and alcohol program including culturally appropriate content and integrating Aboriginal perspectives in facilitator training and delivery
6. CSNSW consider options for increasing the availability of Aboriginal case managers to Aboriginal inmates, particularly those needing additional support to participate in drug and alcohol programs, and seek to increase cultural competency and cultural safety of its workforce through ongoing training, supervision and leadership
7. JHFMHN continue to explore and promote partnerships with Aboriginal Community Controlled Health Organisations to support provision of culturally safe primary health care to Aboriginal patients and explore options for developing funding models enabling partnerships to be developed and sustained long-term
8. JHFMHN continue its work advocating for a trial for access to Medicare for Aboriginal inmates, liaising with equivalent bodies in other states to coordinate advocacy for a trial process involving Medicare access by the Commonwealth to Aboriginal inmates
9. CSNSW and JHFMHN consider convening a high-level meeting to discuss how to better manage chronic inhalant use in custody as a health issue, with consideration given to developing a coordinated therapeutic approach from both services