Inquest into the death of Simon Cartwright

Contributing factors

• Failure to review Simon's known gastrointestinal history on admission
• Reception Screening Assessment completed with errors and without medical record review
• Failure to prescribe proton pump inhibitor therapy despite documented ulcer history
• Failure to arrange timely transfer to mental health facility despite s 86 order on 3 September
• Failure to use alternative s 24 medical transfer mechanism for psychiatric emergency
• Failure to conduct appropriate food and fluid intake monitoring despite medical recommendation
• Inadequate physical observations of inmate in 24-hour surveillance cell
• Denial and management of water access as punitive rather than medical decision
• Failure to recognize Simon's dramatic physical decline despite objective evidence of distress
• Lack of communication between correctional and medical staff regarding Simon's deteriorating condition
• CCTV cameras covered and not cleared for approximately 24 hours without remedial action
• Inadequate mental health training and awareness of correctional staff supervising mentally ill inmates

Coroner's recommendations

1. Justice Health to review policies for monitoring food and fluid intake of inmates to ensure medical recommendations are actioned
2. Justice Health to investigate employing psychologists for therapeutic services to inmates and create systematic support for people with personality disorders in custody
3. Justice Health to consider recommending medical transfer under s 24 Crimes (Administration of Sentences) Act 1999 for psychiatrically ill patients when s 86 Mental Health facility beds are unavailable
4. Corrective Services to implement formal policy on water access including: responsibilities to ensure access, circumstances for disconnection, procedures for disconnection, measures to ensure sufficient access, and record-keeping requirements
5. Corrective Services to ensure adherence with COPP 1.4 subsection 3.4 requiring governor approval for assessment cell placements exceeding 48 hours
6. Corrective Services to consider mandating Mental Health First Aid training for officers supervising inmates in observation cells or on RIT management
7. Corrective Services to develop system ensuring officers know reason for each inmate's placement in observation cell at start of shift
8. Corrective Services and Justice Health to jointly produce memorandum clarifying level of service provided by Corrective Services for observation cell inmates including frequency and nature of physical checks, camera surveillance protocols, and staff allocation