Canisi, Kyle Leslie

Contributing factors

• Failure to implement and document General Manager's direction that O'Connor remain confined to cell
• Failure by acting Area Manager to give clear directions to custodial staff regarding O'Connor's management after 24 December incident
• Custodial staff did not review handover notes or case files before approving association
• Inadequate supervision of prisoners in exercise yard during association
• Lack of risk assessment despite known animosity between prisoners
• No written procedures for prisoner association approval and documentation
• Staff complacency and failure to escalate incident information
• O'Connor's verbal direction to remain in cell not documented in IOMS
• Handling instructions for Canisi not relocated when he was moved to a different cell

Coroner's recommendations

1. AGCC ensure supervisors cross-check IOMS case notes with handover notes to ensure consistency and accuracy during auditing
2. AGCC remind staff about importance of completing intelligence information notices/reports
3. QCS consider removing copy and paste functionality in IOMS concerning case noting
4. AGCC remind staff of requirement for timely and accurate IOMS reporting
5. AGCC remind staff of importance of case noting corrective behaviour directions
6. AGCC develop and use formal and consistent handover note with specific details for incoming personnel
7. AGCC implement robust and documented procedure for DU prisoner association process including risk assessment, authorisation, and documentation
8. AGCC implement procedures for all specific handling instructions to be immediately entered onto IOMS with details and authorisation information
9. AGCC develop and implement specific unit induction training for all staff performing duties in DU
10. AGCC implement robust situational awareness training program to minimise officer complacency
11. AGCC implement robust documented procedure for property within common areas with approval and authorisation process
12. AGCC ensure supervisors and managers receive training on identifying and rectifying risks involving items of property
13. AGCC implement process to ensure verbal handling instructions or directions are immediately relayed to unit officers and entered onto IOMS
14. AGCC review and implement formal diary system for supervisors and managers with annual collection for record retention
15. AGCC ensure adequate procedures so DU officers attend relevant shift briefings unless operational requirements excuse absence
16. AGCC ensure outside personnel attending DU are briefed on specific risks or handling instructions for particular prisoners
17. AGCC implement procedures for medication rounds to minimise exposure to insecure prisoners and opportunity for medication sharing
18. QCS take immediate steps to correct CCTV defect within DU main exercise yard (reduce sun glare)
19. AGCC ensure personnel relieving in roles of Supervisor and Area Manager receive appropriate training on incident command and control