Inquest into the death of Gina Valera

Contributing factors

• Recent suicidal ideation and multiple prior suicide attempts
• Major depressive disorder with inability to access family
• Separation from husband and family
• First-time incarceration in custody
• Inadequate documentation of mental health assessments
• Delay in handwritten notes being entered into electronic system
• Disjointed mental health care between multiple clinicians
• Lack of contemporaneous psychiatric review
• Escalating distress and agitation not adequately identified
• Access to ligature (shoelaces from prison-issued shoes)
• Limited information sharing from Queensland Health at admission
• Availability of hanging points in residential cell

Coroner's recommendations

1. Assistant Commissioner, Strategic Futures, liaise with police to implement a process aimed at achieving consistent information exchange between watch houses and correctional centres
2. Assistant Commissioner, Strategic Futures, revise the COPD At Risk Management to provide clarity in relation to what constitutes a 'recent' suicide attempt
3. Assistant Commissioner, Strategic Futures, ensure when staff are assessing a prisoner's risk of self-harm or suicide they document risk factors and protective factors, and information as to how they have assessed the balance of these factors
4. Assistant Commissioner, Strategic Futures, ensures that the Information Sharing Memorandum of Understanding between Qld Health and Corrective Services maintains capacity for information about personality disorders, psychotropic medication non-compliance, and other relevant information be provided to QCS psychologists when undertaking at-risk assessments and management
5. Assistant Commissioner, Strategic Futures, ensure that the accommodation pathways process be revised with a view to ensuring more detailed information in relation to a prisoner's case notes and at-risk history is included with the Accommodation Committee Decision Record to better inform the committee's decision
6. Assistant Commissioner, Women's Estate ensure that Brisbane Women's Correctional Centre cease the practice of Correctional Supervisor completing Accommodation Pathway forms and the Correctional Centre Officers be tasked with that responsibility, as per COPD Case Management
7. Assistant Commissioner, Women's Estate, ensure there is a suitable peer support prisoner to provide support to another prisoner when it is their first incarceration
8. Assistant Commissioner, Women's Estate, ensure BWCC management take steps to ensure all prisoners receive their unit facility and system inductions within the required timeframe
9. Assistant Commissioner, Women's Estate, undertakes an audit within the Induction Unit to determine there is an adequate level of engagement with prisoners, sufficient advice/information is provided, and staff comply with COPD requirements to case management, admission, an induction
10. Assistant Commissioner, Women's Estate, ensure that BWCC Induction Program is reviewed and expanded to meet the minimum standards as set out with the R9 Minimum Standards Inductions