Inquest into the death of Timothy Garner
Deceased
Timothy Garner
Demographics
31y, male
Date of death
2018-07-07
Finding date
2024-02-01
Cause of death
Hanging
AI-generated summary
Timothy Garner, a First Nations man with bipolar disorder and schizophrenia, died by hanging in custody at MRRC on 7 July 2018, five days after being cleared from Risk Intervention Team (RIT) management. The coroner found it would have been more appropriate for him to remain on RIT management on 10 June, 18 June and 2 July 2018 given his limited engagement with assessors, active psychosis, repeated self-harm attempts and medication non-compliance. He was not reviewed between 2-7 July despite the psychiatrist's plan for follow-up within 3 and 7 days. Administrative processes failed to action the nursing follow-up appointment. Although RIT continuation may not have prevented his death, the evidence demonstrates inadequate psychiatric assessment engagement, failure to implement planned follow-up, and gaps in the assessment of authenticity of his reported mental state during custody reviews.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- Clearance from RIT management despite ongoing psychosis and recent self-harm
- Limited engagement of Timothy with RIT assessors limiting understanding of mental state
- Failure to conduct planned psychiatric and nursing reviews between 2-7 July 2018
- Inadequate assessment of authenticity of Timothy's reported mental state
- Active psychotic illness with paranoid delusions and auditory hallucinations
- Recent medication initiation (olanzapine only 3 weeks established)
- History of repeated self-harm and unpredictable behaviour while in custody
- Administrative failures in actioning follow-up psychiatric and nursing recommendations
- Delays in psychiatrist review (18-31 days vs 14 days guideline)
- Inability to distinguish between instrumental and psychotic behaviour in assessment
Coroner's recommendations
- Commissioner of Corrective Services consider introduction of minimum 5-yearly refresher training for all Risk Intervention Team members
- Commissioner of Corrective Services monitor progress of refurbishments at MRRC to ensure all inmates under RIT management are housed in O-Block or refurbished cells in Darcy Pod by end of 2024
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