Inquest into the death of Gavin Ellis
Deceased
Gavin Ellis
Demographics
31y, male
Date of death
2017-04-02
Finding date
2022-08-18
Cause of death
hanging
AI-generated summary
Mr Gavin Ellis, 31 years old, died by hanging in custody on 2 April 2017 at the Metropolitan Remand and Reception Centre, Silverwater. He had a chronic treatment-resistant schizophrenic illness with extensive self-harm history. Following his psychiatric assessment on 20 February 2017, he was never reviewed by a psychiatrist during six weeks in custody. After identification of suicide risk on 20 March requiring safe cell placement, he spent four days in a camera cell without psychiatric support. He was then transferred to Darcy Unit where no mental health follow-up occurred before his death. The coroner identified critical deficiencies: inadequate psychiatric review frequency, failure to transfer him from Hamden to Darcy waitlist, lack of therapeutic support in safe cells, and insufficient nursing assessment after medication changes. Dr N. concluded standard care required mental health nurse review within days of safe cell release and daily checks given his labile presentation. Systemic issues included resource constraints affecting psychiatrist availability and RIT reviews not meeting 24-hour policy requirements.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- absence of psychiatric review for six weeks post-assessment
- failure to transfer psychiatric waitlist from Hamden to Darcy Unit
- inadequate mental health support during four-day safe cell placement
- no mental health follow-up after release from safe cell to single cell
- medication change (aripiprazole depot) without psychiatric review of side effects
- two medication refusals (31 March, 1 April) not triggering clinical review
- distressing auditory hallucinations and paranoia not adequately managed
- resource constraints limiting psychiatrist availability
- RIT reviews not conducted at mandated 24-hour intervals
- Health Problem Notification Form lacking detail on mental health symptoms
- missed psychiatric appointment on 1 April 2017
- lack of multidisciplinary support (no psychologist, occupational therapist, social worker involvement)
Coroner's recommendations
- Allocate funding as priority to remove ligature points in all Darcy Unit cells at MRRC
- Consider adding requirement for additional random patrols of Darcy cells in roles and responsibilities of officers on B watch at MRRC
- Consider steps to deliver better support and care to inmates in safe cells and recently released from safe cells, including provision of multidisciplinary services (occupational therapists, social workers, psychologists) to minimise mental health deterioration
- Provide further training and education to Justice Health staff in completing Health Problem Notification Forms for inmates subject to RIT, to assist Corrective Services officers identify signs indicating risk of self-harm
- Forward findings to Ministry of Health to support consideration of Care Pathways Model for Custodial Mental Health implementation
Full text
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