Coronial
NSWother

Inquest into the death of Michael Black

Deceased

Michael Black

Demographics

33y, male

Coroner

Decision ofDeputy State Coroner Grahame

Date of death

2020-04-22

Finding date

2025-08-22

Cause of death

stab wound to the chest

AI-generated summary

Michael Black, a 33-year-old First Nations man, died from a stab wound to the chest while detained at Parklea Correctional Centre on 22 April 2020. He was stabbed by fellow inmate Emmett Sheard in a crowded holding cell during a dispute over diverted Suboxone medication. Critical failures contributed to this death: (1) Sheard had been released from segregation prematurely on 31 January 2020 without referral to the High Security Inmate Management Committee despite a recent serious stabbing and extensive violence history; (2) inmates were not searched before placement in holding cell 4, allowing weapons into the cell; (3) 18 inmates were overcrowded in a 5×3 metre cell creating a volatile environment; (4) CCTV camera coverage of the cell was not actively monitored and remained covered for 40 minutes; (5) Michael had requested assessment for opioid substitution therapy since reception on 28 February but had not been assessed by 22 April, contributing to his desperation for diverted medication. Systemic failures in risk assessment, searching procedures, cell management, and healthcare delivery created conditions enabling this preventable death.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

correctional healthaddiction medicineemergency medicine

Error types

diagnosticsystemdelayproceduralcommunication

Drugs involved

buprenorphinebuprenorphine/naloxonemethadone

Clinical conditions

opioid dependenceopioid withdrawalsubstance use disorderdepressionacute pain

Contributing factors

  • premature lifting of segregation direction for Sheard without referral to HSIMC or ETIMC
  • failure to search inmates before placement in holding cell
  • overcrowding of holding cell 4 with 18 inmates in 15 square metres
  • inadequate CCTV monitoring of holding cell
  • camera remaining covered for 40 minutes without detection
  • lack of specified maximum capacity limits for holding cells
  • Michael's untreated opioid dependence and delayed access to opioid substitution therapy assessment
  • removal of Michael from Drug and Alcohol waitlist on 10 March 2020
  • inadequate response to Michael's multiple self-referral requests for medical assessment
  • failure to obtain information about Michael's recent approval for buprenorphine treatment in community

Coroner's recommendations

  1. MTC review procedures, instruction, and training for Segregation Review Committee reviews and formal lifting of segregation directions, with focus on documenting reasons for decisions and appropriate record keeping
  2. MTC review procedures for when inmates should be referred to High Security Inmate Management Committee for HS/EHS designation, with particular attention to violent inmates and weapons possession history
  3. MTC review procedures to expressly require specific correctional officers or supervisors to monitor the number of inmates in holding cells and take steps to prevent unsafe numbers, with instruction on appropriate action when concerns arise
  4. MTC urgently review current limits on maximum number of inmates that can be safely held in Reception Area cells at Parklea, potentially seeking advice from a work health and safety expert
  5. MTC review training and instruction provided to IRT members in responding to violent encounters within cells, drawing lessons from events on 22 April 2020
  6. CSNSW and MTC review arrangements for provision of Serious Incident Reports completed by CSNSW into inmate deaths at MTC-operated centres to MTC
Full text
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