Inquest into the death of KT

Contributing factors

• Ingestion of large amount of clozapine medication
• Presence of methylamphetamine in toxicology
• Failure to follow up abnormal February 2019 plasma test result
• Loss of medication chart for 23-29 April 2019
• Cellmate transfer on 7 May 2019 during period of acute psychological distress
• Denial of permission to attend brother's funeral
• Extended cell lock-in period leaving inmate alone
• Possible accumulation/hoarding of medication doses
• Acute grief and psychological distress following brother's death

Coroner's recommendations

1. That consideration be given to a procedure whereby, if an inmate is classified for normal cell placement and has recently experienced a traumatic event in their life, including the death of a family member, Corrective Services NSW consider the appropriateness of their cell placement, and take steps to: (a) ask the inmate whether they have a preference to be placed with a cellmate (noting that a range of other factors will also influence the ultimate decision as to cellmate placement), and (b) where the inmate is alone, consider whether it is necessary to make observations or otherwise check in on the inmate at reasonable appropriate intervals.
2. That consideration be given to a procedure whereby the Serious Incident Report author reporting on a death in custody contact the police officer in charge of the investigation, to request updating information as to cause of death, prior to signing off on the Serious Incident Report.
3. That consideration be given to providing a copy of the Court's findings in this inquest to the team working on the Pathology Review Project, with a view to informing that Project's consideration of how to regularise the ordering and signing off of clozapine serum level tests.