HARVEY, Thompson

Contributing factors

• Inadequate communication of morphine withdrawal risk between hospital and prison
• Incomplete risk assessment due to inability to conduct full psychological evaluation
• Reliance on prisoner self-reporting without collateral verification
• Poorly documented protective factors in risk assessment
• Downgrade of risk level from medium to low within two days without clear justification
• Missed observation at 07:00 on morning of death due to shift handover gap
• Insufficient documentation of reasoning for risk assessment decisions
• Limited collateral checks to verify reconciliation with partner and other protective factors
• Cell infrastructure containing hanging points (intercom box)
• Unclear rationale for discontinuation of suicide-resistant bedding and clothing after risk downgrade

Coroner's recommendations

1. Cease use of standard, automated or pre-populated wording in prisoner risk assessments and list specific risk and protective factors
2. Professional psychological staff expressly disclose reasoning supporting recommendations specific to individual prisoners
3. Amend risk guidelines so that if protective factors cannot be discussed or are insufficient, prisoners cannot be assessed lower than high risk level (15-30 minute observations)
4. Develop training package for Correctional Supervisors conducting at-risk assessments including collateral checking
5. Remind staff to undertake collateral checks to verify validity and accuracy of prisoner self-reports
6. RAT members consider and verify appropriateness of at-risk prisoner accommodation and express this consideration in At-Risk Management Plans
7. Clarify COPD regarding 'reduced hanging points' and assess whether secure accommodation meets this requirement
8. Ensure ARMP not implemented until ratification process completed by Deputy General Manager
9. RAT Meeting Minutes prepared after meeting to allow full recording of reasoning
10. Even if assessed as low risk, expressly consider whether prisoner should be subject to suicide-resistant clothing/bedding with documented reasoning
11. Cease local practice of one person sighting prisoner and another signing observation log; officer who sights prisoner should sign log
12. Review shift handover procedures to ensure observations between 06:00-07:00 are expressly allocated to relevant supervisor
13. Psychologists record sufficient detail supporting reasoning for cancelling safety orders in both IOMS and RAT minutes
14. All staff reminded to raise SHEH flag and enter sufficient information in accordance with COPD
15. Officers give due consideration to all available information and correlate with prisoner self-reporting; seek collateral information and verification
16. Investigate feasibility of safer cells and 'safe cell' design infrastructure with reduced hanging points, particularly intercom boxes
17. Publish annual updates on implementation of safer cells strategy and progress against that strategy
18. All Correctional Officers receive additional training on responsibilities for management of incidents including apparent good health checks
19. Staff reminded of responsibility to immediately alleviate pressure on prisoner's neck during response to hanging
20. All CCC staff undergo further training on life-saving measures in circumstances involving possible death in custody and medical emergencies
21. Staff trained on requirements for first aid and commencement and continuation of life-saving measures
22. Complete Death in Custody Management Checklist and conduct Level 2 operational debrief following incidents
23. Amend COPD to require Form 193 Debrief Workshop be used as reference for future incident debriefs