Ahquee, Dylon James

Contributing factors

• Failure to raise Self-Harm Episode History (SHEH) flag despite documented juvenile self-harm history
• Failure to identify as Elevated Baseline Risk (EBLR) and initiate corresponding management
• Placement in non-suicide-resistant cell despite induction assessment recommending modern suicide-resistant cell
• Failure to complete Assessment Services follow-up after referral for low mood presentation in early December 2015
• Breakdown in local assessment process for prisoner-of-concern referrals
• Lack of case note documentation regarding double-up cell placement with fellow at-risk inmate
• Overcrowding impacting single-cell availability
• Absence of documented risk assessment for shared accommodation placement

Coroner's recommendations

1. Audit of prisoner files to ensure all prisoners with history of self-harm have appropriate SHEH flags activated on IOMS
2. Specific orientation and induction provided to staff in offender development supervisory and management positions
3. Review of local processes and practices for raising SHEH flags and commencing EBLR process
4. Review of agency EBLR process to ensure effectiveness and efficiency in identifying and responding to prisoners' risk of suicide/self-harm
5. Review of local processes to ensure compliance with COPD (Custodial Operations Practice Directives) requirements and best practice standards
6. Review of local training, supervision and practice support provided to staff regarding at-risk management and assessment
7. Review of agency training, supervision and practice support provided to staff regarding at-risk management and assessment
8. All staff at TCC reminded of responsibilities regarding COPD requirements for shared cell placements
9. Amendment to local forms to ensure shared cell placements are adequately assessed, identified risks are mitigated, and appropriate record keeping is maintained
10. Agency review of prisoner numbers and capacity utilisation to identify and implement strategies to reduce overcrowding
11. TCC to review accommodation placement model and decisions to ensure all reasonable efforts taken to ensure prisoners with self-harm history and EBLR accommodated in modern suicide-resistant cells
12. Agency review of infrastructure to ensure adequate accommodation for prisoners with self-harm history and EBLR
13. Queensland Government to publish annual updates detailing strategy for implementation of safer cells and progress against that strategy