Adams, Michael James

Contributing factors

• Inappropriate placement in Unit 7B despite documented safety concerns
• Inadequate risk assessment upon return from hospital
• Failure to consider psychiatric/psychological status following overdose
• Lack of secure cell design allowing access by other prisoners
• Insufficient observation protocols and monitoring
• Delayed emergency response and medical apparatus availability
• Illicit drug availability within correctional facility
• Lack of privacy interview facilities for vulnerable prisoners

Coroner's recommendations

1. Provision of formal interview facilities in custodial centres for private secure areas relating to prison investigations
2. Prison cells designed with self-locking devices to prevent fellow prisoner access once door is closed
3. Protocols to prohibit objects blocking clear observation of cell interiors (e.g. towels over observation windows)
4. Developed and monitored protocols for securing cells and scenes of death in custody to prevent evidence contamination
5. Video surveillance of all cells and areas where prisoners are reasonably likely to be located, balancing safety against privacy concerns
6. Urgent proactive removal of all potential hanging points in all prisons
7. Reasonable access to telephone contact with next of kin at nominated times, monitored by reliable mechanical devices
8. Established protocols ensuring meaningful communication between hospitals and prisons regarding prisoner discharge, with professional assessment of physical, mental and psychological status prior to placement decisions
9. Protocols for management of prisoners who have taken unprescribed drugs to prevent recurrence and ensure proper supervision
10. More timely practice for Emergency Services attendance at critical incidents with immediate provision of medical apparatus and oxygen
11. Urgent active and proactive programme to eliminate illicit drugs from correctional facilities, including random inspection of prisoners and cells by trained personnel and drug detection dogs