Malone, Terrence Michael
Deceased
Terrence Michael Malone
Demographics
54y, male
Date of death
2014-11-08
Finding date
2019-05-08
Cause of death
incised wound to the neck
AI-generated summary
Terrence Michael Malone, a 54-year-old man with a 20-year history of bipolar affective disorder, PTSD, and alcohol dependence, died by suicide in Brisbane Correctional Centre on 8 November 2014, three days after re-incarceration. Key clinical lessons: (1) suicide risk is dynamic and must be reassessed in custody despite recent low-risk assessments in hospital; (2) integrated assessment of mental health and substance use is essential—his separate treatment as siloed issues in hospital and prison contributed to inadequate care; (3) early imprisonment is highest-risk period, yet he was not placed on observations despite prior week's 30-minute watch-house observations and recent suicidal ideation at hospital; (4) collateral information and recent history were not communicated or accessed by prison staff; (5) unmanaged chronic pain from untreated shoulder injury and alcohol withdrawal contributed to distress. The coroner found the hospital's EEO assessment appropriate but criticised lack of holistic, person-centred approach and failure to advocate for detoxification admission.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- inadequate mental health risk assessment on entry to prison
- failure to place on observations regime despite recent watch-house observations and suicidal ideation
- lack of communication of mental health history from watch house to Brisbane Correctional Centre
- absence of self-harm flag on prison information system
- inadequate access to prior mental health records during prison intake assessment
- provisional psychologist conducting assessment with limited training
- lack of holistic, person-centred approach at hospital and prison
- siloed treatment of mental health and alcohol dependency issues
- chronic untreated pain from shoulder fracture
- alcohol withdrawal without adequate monitoring
- discharge from rehabilitation program without adequate follow-up
- parole suspension decision without adequate attempts to locate prisoner
- provision of razor blades to high-risk prisoner in early incarceration
- lack of face-to-face psychiatric consultation in hospital
Coroner's recommendations
- Queensland Corrective Services should develop a policy in relation to the management of risks associated with provision of razor blades to prisoners within the first month of entry to prison, particularly where a prisoner has recently expressed suicidal ideation or has recently been discharged from hospital emergency department following an Emergency Examination Authority
- Queensland Corrective Services, in partnership with Queensland Health, should review its approach to suicide risk assessment and assertive responses to suicide risk in the context of best practice approaches
- These findings should be provided to the Queensland Mental Health Commission and the Strategic Leadership Group overseeing implementation of the Mental Health, Alcohol and Other Drugs Strategic Plan to inform enhancement of responses to persons with co-occurring mental illness and substance use disorders who are at risk of entering or have entered the criminal justice system
- Queensland Government should consider an increase in funding to enable QCS to enhance the IOMS system to support recommendations of the Office of the Chief Inspector to enable risk assessment information to be displayed and accessible for QCS staff within a drop-down menu
- Queensland Government should consider an increase in funding to enable QCS to be a competitive employer to attract and retain experienced psychologists and senior psychologists within custodial settings
- Queensland Government should consider a trial program for 'Front End Services' of intake, health assessment and mental health assessment at the Brisbane City watch house involving collaboration between Queensland Corrective Services, Queensland Health, Queensland Police Service and the Prison Mental Health Service
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