Blair, Colin Wayne

Contributing factors

• Inadequate communication between Risk Assessment Team and Sentence Management regarding accommodation and transfer decisions
• Prisoner informed of imminent transfer from unit S3 without knowledge of RAT recommendation to remain in unit S3
• Loss of protective factors: accommodation concerns and family not able to assist
• Mental health history including personality disorder, polysubstance abuse, and previous suicide attempts
• Inadequate observations at 1:30pm muster and 2:00pm
• Availability of electrical cord from television as potential ligature in cell
• Delay in PMHS triage and intake assessment
• Parole release on Friday afternoon with inadequate community support planning

Coroner's recommendations

1. Queensland Corrective Services should ensure that Sentence Management staff are oriented to and understand the RAT process, NOC process, and related risk assessment outcomes
2. Queensland Corrective Services should implement local procedures requiring psychologists to accompany Sentence Management staff when conducting classification and placement assessments or notifying at-risk prisoners of transfers, with review of relevant materials including RAT minutes
3. Queensland Corrective Services should implement procedures for obtaining collateral information from watchhouse where prisoners were managed on observations prior to admission, including stamping prisoner files 'Suicidal' where appropriate
4. Queensland Corrective Services should provide collateral information gathering training for reception assessment psychologists
5. Queensland Corrective Services and Queensland Health should consider amendments to the Memorandum of Understanding on Confidential Information Disclosure to optimise information sharing and protect health practitioners from liability
6. Queensland Health and Queensland Corrective Services information sharing working group should consider whether QCS psychologists require more access to Consumer Integrated Mental Health Application (CIMHA) records
7. Queensland Corrective Services should enhance the IOMS system to support risk assessment information display accessible via dropdown menu
8. Queensland Government should consider increased funding to enable QCS to attract and retain experienced psychologists in custodial settings
9. Queensland Government should review provisions for delayed or early release of prisoners under special circumstances where the release date is detrimental to the prisoner
10. Queensland Corrective Services should ensure re-entry services are appropriately resourced to support late and weekend releases, provide crisis support 7 days per week, and deliver needs assessments linking to support for prisoners being released from self-harm management