Holstein, Zachary James David

Contributing factors

• History of substance abuse and self-harm
• Previous trauma (death of partner in 2013)
• Delay in medical assessment (16 days from request to first VMO consultation)
• Inadequate resourcing of Offender Health Services at the correctional centre
• Limited consultation capacity at the medical centre
• Lack of documented clinical follow-up after medication initiation

Coroner's recommendations

1. Metro North HHS urgently consider additional resourcing of Offender Health Services within Woodford Correctional Centre (both staffing and number of consultation rooms) to ensure prisoners are able to see a doctor within at least seven days after triage for non-urgent consultation, and ideally within a few days, commensurate with timeframes in the general community
2. Office of Chief Inspector, Queensland Health and all Hospital and Health Services who provide health services to prisoners jointly consider ways for ensuring that where a prisoner dies and health services provided are relevant to OCI investigation, there is a mechanism for gathering relevant QH and HHS information including interviews with staff
3. OCI review investigation and report into Holstein's death to identify opportunities for improvement to OCI investigation policies, processes and training, particularly in relation to Root Cause Analysis methodologies
4. Where OCI reports make findings and recommendations about services provided by QH and HHS, reports be provided in draft form to QH and HHS for comment prior to finalisation