Inquest into the death of Russell Zaska
Deceased
Russell Gary Zaska
Demographics
33y, male
Coroner
Decision ofDeputy State Coroner Kennedy
Date of death
2020-09-23
Finding date
2024-08-22
Cause of death
hanging
AI-generated summary
Russell Zaska, a 33-year-old man with a complex mental health history including probable methamphetamine dependence and recurrent drug-induced psychosis, died by hanging in custody at the Metropolitan Remand and Reception Centre on 23 September 2020. He had been remanded in custody for three weeks. Despite psychiatric assessment on 15 September identifying psychotic symptoms and thought disorder, he was commenced on antipsychotic medication (Olanzapine) and referred to the Hamden Unit for more intensive mental health care. However, due to lengthy waiting lists, he remained in general population accommodation. The coroner found systemic under-resourcing of mental health facilities in prisons critically concerning. Key clinical lessons include: better screening and earlier assessment might have identified psychiatric needs sooner; consideration of more intensive mental health facility placement (MHSU rather than Hamden) for acutely psychotic patients; exploration of section 24 transfers to external psychiatric hospitals when prison mental health services cannot provide appropriate care; better assessment of suicide risk in psychotic patients, particularly those with thought disorder and unreliable history; and importance of family contact as protective factor, which was inadequately facilitated.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- psychotic episode with thought disorder
- inadequate mental health facilities and long waitlists in prison system
- delay in accessing recommended Hamden Unit placement
- failure to facilitate family contact as protective factor
- insufficient assessment of suicide risk in context of acute psychosis
- lack of hybrid or medium-restrictive care options between assessment cell and normal placement
Coroner's recommendations
- Corrective Services NSW and Justice Health and Forensic Mental Health Network should continue to advocate for and seek additional resources to address the chronic under-resourcing of mental health care in the prison system
- Training and education should be provided to RIT teams to ensure awareness and consideration of all available risk management options, including medium-restrictive options such as transition cells with hourly visual checks, rather than the binary choice between assessment cells and normal placement
- Corrective Services NSW should continue promoting the use of transition cells (reduced hanging points, CCTV monitoring, less restrictive than assessment cells) and provide ongoing training to RIT members about their appropriate use
- Consideration should be given to the use of section 24 of the Crimes (Administration of Sentences) Act 1999 to facilitate transfer to external psychiatric hospitals for treatment when the recommended level of mental health care cannot be provided within the prison system
- At reception, staff should make best practice efforts to facilitate family contact, including exploring potential contact details, accessing records from previous custodial episodes, or ensuring priority SAPO referral when inmates do not have family phone numbers
- Inmates without buy-up money should be proactively advised of the policy allowing two letters per week at the expense of Corrective Services
- Mental health assessments should place greater weight on objective behavioral indicators and signs of mental illness, particularly in unreliable historians and those with thought disorder, rather than relying primarily on self-report of suicidal ideation
Full text
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