Inquest into the death of Geoffrey Fardell
Deceased
Geoffrey Fardell
Demographics
52y, male
Date of death
2019-06-10
Finding date
2024-09-06
Cause of death
Neck compression (ligature strangulation)
AI-generated summary
Geoffrey Fardell, a 52-year-old man with schizophrenia, HIV, and substance abuse history, died from neck compression (strangulation) while in remand custody at Mid North Coast Correctional Centre. He was placed in a cell with Richard Reay, a violent maximum-security inmate with recent segregation for violence, despite Fardell being a vulnerable C1-classified inmate on protective custody. No compatibility assessment was documented prior to cell placement, contrary to policy requirements. The coroner found that proper application of existing procedures—checking alerts and assessing compatibility—would likely have prevented this death. Corrective Services NSW subsequently implemented comprehensive policy changes including mandatory compatibility assessments, decision-recording requirements, and local operating procedures to prevent similar incidents.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to conduct compatibility assessment prior to cell placement
- Failure to check alerts on existing cellmate (Mr Reay) before inmate placement
- Lack of documentation regarding cell placement decision-making process
- Placement of vulnerable protective custody inmate with known violent offender
- Stark contrast in security classification and risk levels not considered
- Both inmates on SMAP but with fundamentally different protection needs
Coroner's recommendations
- Mandatory compatibility assessment for all inmates placed in shared cells, checking both incoming and existing inmates
- Implementation of cell placement decision guide to assist officers in determining appropriate placements based on risk of harm and compatibility
- Recording of all cell placement decisions on Offenders Information Management System with officer name and reasoning documented
- Review of inmate cell placement decisions when negative changes in circumstances or behaviours occur
- Education and training regarding significance of Supreme Court supervision orders in placement decision-making
- Senior Correctional Officer Accommodation responsibility for inmate movements in designated sectors
- All pod officers responsible for checking alerts prior to moving or receiving inmates
Full text
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