Inquest into the death of Emmett Brown

Contributing factors

• consumption of non-prescribed methadone whilst in custody
• failure to perform mandatory chronic disease screening for Aboriginal inmate
• failure to timely reassess and monitor inmate at risk of opioid dependence
• long wait times for drug and alcohol assessments (3 months)
• inadequate head-check procedure on morning of death
• high BMI (38.75) and undiagnosed obstructive sleep apnoea
• wide availability of diverted methadone and other unprescribed medications in custody
• systemic failure to record Indigenous status in Justice Health electronic system

Coroner's recommendations

1. CSNSW review written procedures and training for confirmation of inmate physical wellbeing during head-checks, including: (a) reviewing COPP 5.3 to clarify whether verbal AND physical response is required; (b) reviewing sufficiency of training for recruits and serving officers; (c) conducting refresher practical training for all custodial staff conducting head-checks; (d) reviewing Local Operating Procedures for consistency across correctional centres
2. CSNSW review written procedures and training concerning incident response and reporting for medical emergencies and deaths in custody, including: (a) requiring separation of involved officers until incident reports completed, subject to operational considerations; (b) mandating officers not discuss events or review footage until reports submitted; (c) requiring senior officer to manage and supervise initial incident reporting; (d) providing clear guidance on what constitutes medical emergency
3. Justice Health examine arrangements and resourcing regarding wait times for Drug and Alcohol assessments and reviews with aim of reducing wait times