Mataia, Tofia Josen

Contributing factors

• Failure to identify involuntary treatment order when prisoner remanded
• Inadequate mental health assessment on arrival at prison
• Failure to access prior mental health records from Cairns Mental Health Unit
• Poor dissemination of violence risk information to supervising officers
• Lack of staff training in restraint asphyxia dangers
• Inadequate monitoring of prisoner health during restraint
• Prone positioning with multiple officers applying downward pressure
• Obesity and abdominal splinting during prone restraint
• Prolonged violent struggle preceding restraint
• Delay in calling ambulance
• Inadequate nursing response to medical emergency
• Absence of defibrillator when nurses arrived
• Schizophrenia with psychotic episode
• Underlying severe coronary atherosclerosis

Coroner's recommendations

1. Recommendation 1: QCS ensure all senior managers are aware of the limited number of officers authorized to make and cancel Safety Orders and of the requirement that upon cancellation of such an order consideration be given to the need to make an Intensive Management Plan
2. Recommendation 2: Commissioner of Corrective Services cause all correctional centres to amend policies so that whenever an employee has reason to believe a medical emergency exists, they should be required to call QAS without waiting for a nurse to examine the prisoner
3. Recommendation 3: Queensland Corrective Services Commissioner seek assistance from CSIU to review existing crime scene and evidence preservation policies at all correctional centres and provide training to CSOs
4. Recommendation 4: Commissioner of Corrective Services consider seeking amendment to Corrective Services Act to require any person with information about a death in a correctional centre to provide that information to CSIU officers with proviso that information cannot be used against them in criminal or disciplinary proceedings