Coroner's Finding: Brian Gerard Dunningham

Contributing factors

• Psychotic illness with suicidal and depressive symptoms
• Premature cessation and inadequate dosing of antipsychotic medication
• Disruption of continuity of psychiatric care due to transfer from Parklea to Bathurst on 5 August
• Failure to arrange urgent psychiatric review at Bathurst despite it being scheduled for 5 August
• Failure of Justice Health staff to review his medical records at Bathurst
• Inadequate mental health staffing resources at Bathurst (90-person waiting list, only 1 FT mental health nurse position shared by 2 staff)
• Multiple hanging points in cell without protective mesh
• Loss of family contact and support due to distance of Bathurst from family home

Coroner's recommendations

1. Compulsory mental health training for all nursing staff employed by Justice Health
2. Urgent review of all aspects of care and treatment of Brian Dunningham from reception in March 2009 until death in September 2009, to be provided to CEO and Board Chair by 30 September 2011
3. Urgent review of staffing levels at Parklea Prison and Bathurst Correctional Centre to address waiting lists for mental health services; consider appointing at least one additional full-time mental health nurse position at each centre
4. Consider ways of improving access to healthcare for inmates on protection or in SMAP programme
5. Consider amending Clause 297 of Crimes Administration of Sentences Regulation 2008 to allow details of special mental health needs to be communicated to staff responsible for prisoner transfers
6. Consider allocating a Case Officer to an inmate immediately after case plan development, regardless of jail classification