Inquest into the death of Phuoc Van Nguyen

Contributing factors

• physical altercation with fellow inmate precipitating transfer request
• transfer from minimum to maximum security creating significant change in circumstances
• potential prior planning of self-harm via arranged protective custody transfer
• inconsistent mental health screening and conflicting reporting of mental health history
• presence of prior self-harm alert from 2016 not given sufficient weight in current assessment
• lack of dedicated risk assessment for self-harm prior to transfer from Area 4 to Main Centre
• uncertain origin and source of ligature material
• inadequate awareness and training of correctional staff regarding Instruction PKL025

Coroner's recommendations

1. Review and amend Instruction No: PKL 025 to expressly provide for a specific timeframe within which an inmate transferring from Area 4 to the Main Centre is to be assessed for risk of suicide and self-harm
2. Review and amend Instruction No: PKL 025 to expressly provide for what is to occur if a qualified RIT coordinator and a RIT qualified Shift Manager are unavailable to assess an inmate transferring from Area 4 to the Main Centre for risk of suicide or self-harm
3. Ensure all correctional staff to which Instruction No: PKL 025 applies are aware of its contents and understand accurately its terms through education, training or communication