Inquest into the death of Patience Kuzmins
Deceased
Patience Kuzmins
Demographics
23y, female
Date of death
2022-11-10
Finding date
2026-06-19
Cause of death
Methylamphetamine toxicity
AI-generated summary
Patience Kuzmins, 23, died in custody at Silverwater Women's Correctional Centre on 10 November 2022 from methylamphetamine toxicity caused by an internally concealed package. The coroner found that Patience was not strip-searched in accordance with CSNSW policies on 7 and 8 November 2022, partly due to shortage of female correctional staff. Critically, information about the missed search was not recorded on her inmate lodgement sheet or communicated to receiving facilities. Additionally, a body scan of a fellow inmate was misinterpreted by an inexperienced operator, failing to detect internally concealed contraband, so this inmate remained in the holding cell with Patience rather than being placed in a dry cell. However, the coroner could not definitively conclude whether these procedural failures directly allowed the drug concealment. The coroner recommended emphasising search completion status on lodgement forms and providing better training and support for body scan operators.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Failure to perform strip search in accordance with CSNSW policies on 7 November 2022 due to shortage of female correctional staff
- Failure to record non-completion of search on New Inmate Lodgement Sheet
- Failure to search inmate at Amber Laurel Correctional Centre on 8 November 2022 due to lack of documented information
- Misinterpretation of body scan image of fellow inmate on 9 November 2022 by inexperienced operator
- Failure to place fellow inmate in dry cell following suspicious body scan findings
- Data synchronization issue preventing body scan of inmate prior to placement with Patience
- Multiple opportunities for transfer of contraband between inmates during reception and holding periods
Coroner's recommendations
- Consideration be given to ways in which information required by the New Inmate Lodgement & Special Instruction Sheet relating to whether an inmate has been searched can be emphasised or highlighted to ensure that it is properly and accurately completed
- Consideration be given to the ways in which support can be provided to both less experienced operators of body scanning machines to improve detection skills, and more experienced operators to prevent degradation of existing detection skills, including how best to communicate the availability of electronic and online resources and any common themes, issues or trends relating to body scanning
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