Mills, Samuel John

Contributing factors

• Chronic schizophrenia inadequately managed despite treatment attempts
• Poor continuity of mental health care due to under-resourcing of prison mental health services
• Loss of critical historical information about previous suicide risk assessments from 1998-1999 due to paper-based records not transferred to electronic system
• Inadequate mental health staffing: only one psychiatrist session per week for 400-prisoner population
• Prison ward design with multiple hanging points despite known high suicide risk in custodial settings
• Drug abuse and medication non-compliance despite forensic order requirements
• Limited psychosocial support and psychotherapy availability in correctional setting

Coroner's recommendations

1. The Department of Corrective Services should audit its hard copy files to ensure records of previous self-harm attempts are added to the Integrated Offender Management System (IOMS) to improve access to critical risk information
2. The State Government should immediately provide sufficient funding to remove exposed bars and other hanging points in all cells at Lotus Glen Correctional Centre, consistent with the Royal Commission into Aboriginal Deaths in Custody recommendation
3. Queensland Health should review funding for the new position of forensic psychiatrist in Cairns with a view to increasing it to 1.0 FTE (rather than 0.5 FTE) to provide adequate mental health services for the expanded prison population and community mental health consumers