Inquest into the death of Kerry-Ellen (Nikki) Knight
Deceased
Kerry-Ellen (Nikki) Knight
Demographics
44y, female
Date of death
2021-03-05
Finding date
2022-09-28
Cause of death
Hanging
AI-generated summary
Kerry-Ellen Knight, aged 44, died by suicide in custody at Silverwater Women's Correctional Centre on 5 March 2021 after only 6 days in custody. She was in COVID-19 quarantine in an old-style cell with prominent hanging points. Multiple clinical opportunities were missed: the initial mental health screening failed to identify her known PTSD, anxiety and depression despite these being documented in available electronic records; her self-referral form requesting urgent mental health medication was incorrectly triaged as non-urgent despite clear signs of mental health deterioration; and her verbal requests for medical assistance on the morning of her death were not escalated appropriately. Staff did not consult available electronic health records when they should have. Her distress was compounded by inability to contact family, boredom and isolation during quarantine, and being left alone in her cell after her cellmate was removed for court. The coroner found the death may have been preventable, with failures in mental health assessment processes, record review, escalation protocols, and risk assessment communication between services.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Failure to review available electronic health records during mental health screening assessment
- Failure to identify and reconcile discrepancy between patient's denial of PTSD and documented PTSD diagnosis
- Incorrect triage of self-referral form as non-urgent despite clear mental health deterioration
- Failure to escalate patient's verbal requests for medical assistance on morning of death
- Inadequate assessment of suicide risk
- Presence of prominent hanging points in cell
- COVID-19 quarantine isolation and lockdown
- Patient left alone in cell after cellmate removed
- Inability to contact family by phone
- Boredom and frustration during quarantine with limited activities
- Recent severe psychosocial stressors including relationship breakdown and family conflict
- Childhood trauma and untreated mental health conditions
Coroner's recommendations
- Immediate consideration be given to piloting and supporting a Peer Support Program (such as the Listeners Program) aimed at improving mental health support in custody, with the pilot to commence at a women's prison as soon as possible in full consultation with JHFMHN
- Cell 5 and other like cells in F Wing of Silverwater Women's Correctional Centre be refitted to remove hanging points or decommissioned as soon as practicable
- Further consideration be given to initiatives that would alleviate boredom and isolation for inmates kept in COVID-19 quarantine, including but not limited to allowing immediate access to telephone services irrespective of financial issues, increased time out of cells and recreational activities
- CSNSW review its processes to ensure that a record is made when there is a knock up call that requires attendance at a cell by CSNSW and/or a request to be made for attendance by JHFMHN
- JHFMHN give consideration to making it a requirement to scan and upload any patient self-referral form into the patient's electronic medical record
- JHFMHN amend Justice Health Policy 1.225 to include a requirement for the nurse conducting the RSA to undertake a review of medical records, particularly where information is inconsistent with PAS alerts or health conditions
- JHFMHN review its processes for recording verbal requests received from CSNSW for attendance on an inmate in relation to a medical issue
Full text
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