Carroll, Leon Mark

Contributing factors

• Initial high-risk assessment of suicide/self-harm not adequately sustained
• High Risk Assessment Team review conducted in only 5-6 minutes with insufficient consideration
• Time between initial risk assessment and reassessment was too short
• Inadequate resourcing and workload of HRAT (10-12 reviews per hour)
• Psychologist conducting reassessment lacked access to social worker's initial assessment notes and prisoner's medical file
• Availability of hanging points in cell (louvre window bars)
• Prisoner moved to sole occupancy of cell after cellmate transfer, reducing informal observation
• Apparent normalization of mood and behaviour ("smiling depressive" presentation masking fixed suicide intent)

Coroner's recommendations

1. Review mechanisms and procedures to reassess prisoners initially assessed as 'at risk' before removing close observation, to ensure decisions have a sufficient evidence base
2. Review and increase resources of the High Risk Assessment Team to enable more careful and extensive consideration of each matter coming before the team
3. As a matter of urgency, cause cells at Arthur Gorrie Correctional Centre to be modified to remove hanging points by covering bars with mesh