Death of a prisoner

Contributing factors

• despair regarding lengthy potential prison sentence
• anticipated relationship breakdown with wife and limited contact with children
• cessation of antipsychotic medication 14 days prior to death
• delayed psychiatric assessment after custodial admission
• impulsive suicide decision not detectible by prison or family members

Coroner's recommendations

1. QCS media section policies be amended to stipulate that before a media release is issued in relation to death in custody, the responsible officer must establish whether the deceased prisoner's contact person and next of kin have been advised. No information likely to enable identification should be released until reasonable efforts to notify family have been made.
2. QCS review policies to ensure procedures exist requiring fully informed decisions about contact between respondents to domestic violence orders in custody and victims/aggrieved persons, ensuring such contact does not breach DVO terms.
3. Current QCS policies now require apparent death to be treated as medical emergency requiring commencement of life-saving measures unless and until health staff advise otherwise (policy already implemented).
4. PMHS documented procedure for response to cessation of psychotropic medication (policy already implemented).