Davis, Jodie Maree

Contributing factors

• inadequate suicide prevention training for psychology staff
• very junior and inexperienced psychology staff (3-4 months experience)
• lack of access to previous medical records by psychology staff
• insufficient psychiatric consultation and follow-up
• inadequate observation frequency (2-hourly standard when more frequent monitoring recommended)
• poor retention of experienced psychologists leading to staff shortages
• failure to establish adequate rapport with difficult patient
• patient non-compliance with medication
• obvious hanging points (bars on louvres) in cell not removed
• lack of formal suicide risk assessment training assumed to be included in psychological training but not provided
• crisis support unit policies that respected patient autonomy but may have been insufficient for very high-risk individuals

Coroner's recommendations

1. All medical files, including previous hospital files, be made accessible to prison psychology staff with copies kept in prison psychology files
2. Sentencing remarks and copies of reports tendered on sentence be made available to prison psychological staff
3. Senior psychologist be consulted regarding review of operational procedures especially for reception, CSU, and suicide prevention
4. Standard operating procedures incorporate provision for observation frequency greater than 2-hourly on psychologist recommendation, with staff levels adapted accordingly
5. Psychologists without recent suicide prevention training receive such training within 24 hours of employment, repeated at regular intervals
6. Incentives at least equal to public sector offered to attract and retain experienced psychological professionals
7. Salaries and conditions of psychologists employed by Queensland Corrective Services be at least at same level as other public sector psychologists in Queensland
8. Professional supervision be routinely funded and undertaken during paid working hours
9. Attendance at workshops and conferences be funded on regular basis
10. Essential professional role of psychologists in suicide prevention be formally recognised by prison management and communicated to correctional officers and medical staff
11. Protocol be developed with Queensland Ambulance for feedback from officers attending emergencies at prison to assist in improving emergency response
12. Contact with next of kin and regular visitors be made by counselling professionals for prisoners assessed as at-risk of self-harm to gain insight and assist management
13. Nursing staff at correctional centres be provided opportunity to shadow emergency workers at hospital emergency departments or with ambulance officers
14. Correctional officers with first aid training be given opportunity to regularly update skills with funding provided
15. Obvious hanging points including bars be immediately retrofitted with alternative security such as mesh to reduce hanging opportunities