Inquest into the death of Daniel Munro Lewis Turnbull

Contributing factors

• Undetected psychogenic polydipsia developing rapidly in context of schizophrenia
• Lack of clinical observation protocols specified in health management plan
• Limited monitoring of non-RIT inmates in 24-hour surveillance cell
• Correctional officers unaware that excessive water intake could be life-threatening
• Miscommunication between Justice Health and Corrective Services about observation levels
• Absence of knowledge among correctional officers regarding signs of hyponatraemia
• Placement in isolation cell with water access but without enhanced clinical monitoring
• No documentation of observed behaviours before collapse

Coroner's recommendations

1. Correctional officers in correctional settings to be informed and educated that: (1) excessive water intake particularly in short period of time can be life-threatening; (2) intervention should occur before person shows signs or complains of symptoms; and (3) if person develops symptoms/signs, it is a medical emergency
2. CSNSW and Justice Health and Forensic Mental Health Network to revise policies and Health Plan Notification Form to reflect that excessive water ingestion particularly over short period can be life-threatening, and any symptoms/signs suggesting excessive water ingestion require immediate intervention regardless of whether inmate identifies it as concern
3. CSNSW to produce memorandum outlining what level of supervision/observation service is provided to inmates in observation cells (including 24-hour surveillance cells) - specifying types of physical checks, frequency, camera surveillance coverage, staffing and viewing arrangements, whether officers aware of why inmate placed in cell, how information passed between shifts, and what officers instructed to look for - to be provided to Justice Health for circulation to clinical staff