Inquest into the death of AB

Contributing factors

• Self-harm incident on 20 January 2021 required transfer and surgical repair but no formal psychiatric review was conducted upon return to custody
• Discharge from Risk Intervention Team management based on assessment by single mental health nurse without senior/specialist psychiatric input
• Placement in single cell on 27 January 2021 contrary to recommendation for two-occupant cell
• Cell 64 was not searched prior to AB's placement despite recent self-harm risk, allowing access to razor blade fragment
• Limited mental health screening on custody admission did not adequately capture risk given inconsistency between AB's denials and his documented mental health history
• Lack of chaplain or informal support service referral following first self-harm incident

Coroner's recommendations

1. Patients who require surgical intervention as a result of suicide or deliberate self-harm behaviour should be referred for a specialist mental health assessment (now implemented in Justice Health policy from November 2021)
2. Consider establishing clear guidelines on the timeframe for maintaining an inmate under restrictive conditions to mitigate suicide risk
3. Improve visibility of an inmate's mental health history via alert system or summary available at commencement of electronic medical record (now implemented with updated Justice Health systems)
4. Seek opportunity to reduce the number of mental health staff involved in RIT process and increase consistency of staffing to provide RIT assessments
5. Ensure all cells are searched prior to placement of inmates subject to Mandatory Notification, Immediate Support Plan or Risk Intervention Team Management Plan (now implemented in CSNSW Custodial Operating Policy and Procedures)
6. Maintain updated alerts on patient administration systems identifying all mental health concerns and RIT review dates