Inquest into the death of GS

Contributing factors

• Failure to provide psychiatric medication review despite multiple explicit requests over 183 days
• Systemic failures in patient administration system waitlist management
• Patient triaged as category 3 (non-urgent) and never escalated despite cumulative requests
• No face-to-face assessment by medical practitioner of psychiatric medications prescribed in community
• Delay in initial medication provision—took almost one month despite two RIT assessments
• Frequent transfers between correctional facilities (six centres) disrupting continuity of care
• Inadequate communication and information sharing between CSNSW and Justice Health
• Lack of integrated assessment of cumulative mental health needs
• Bullying and threats from other inmates creating isolation and distress
• Recent bail denial creating perception of extended incarceration
• Placement in one-out cell with ligature points shortly after emotionally distressing phone call
• Staff lack of awareness of full mental health history when making placement decisions
• Resource constraints limiting availability of mental health clinicians

Coroner's recommendations

1. CSNSW and Justice Health implement a written policy that inmates being transferred due to safety concerns and placed one-out pending transfer be referred to Justice Health for assessment
2. Justice Health examine PAS Waiting List Priority Level Protocol and clarify clinical priority for mental health patients with multiple medication review requests while on waitlist
3. Justice Health introduce written policy requiring staff to record each time a patient on existing waitlist makes further request for review by corresponding clinician
4. Justice Health amend PAS Waiting List Priority Level Protocol to guide nursing staff triaging patients overdue for assessment relative to their clinical priority category
5. Justice Health clearly separate reporting of overdue patients on Overdue PAS report into discrete clinical priority categories to allow analysis of delays, particularly category 3
6. St Vincent's Correctional Health examine Triage and Priority Waitlist policy and clarify clinical priority for mental health patients with multiple medication review requests
7. St Vincent's Correctional Health introduce written policy requiring staff to record each time a patient on existing waitlist makes further request for review by corresponding clinician
8. St Vincent's Correctional Health amend Triage and Priority Waitlist policy to guide nursing staff triaging patients overdue for assessment relative to their clinical priority category
9. GEO Group Australia Pty Ltd implement written policy that inmates at Junee Correctional Centre being transferred due to safety concerns and placed one-out pending transfer be referred to health staff for assessment