Coroner's Finding: LINDSAY Margaret

Contributing factors

• failure to read and communicate critical information from police about suicide risk at intake
• failure of Correctional Services Officers to properly implement risk assessment procedures despite established screening form
• high-risk assessment (score 20/20) ignored by admitting staff
• inadequate supervision of junior intake officer by supervisor
• failure to exchange information between custodial and health staff
• failure to implement cell-sharing recommendation for Aboriginal detainees
• failure to remove identified hanging point from cell (gap between bookshelf and wall)
• placement in standard cell rather than observation cell despite clear risk indicators
• practice of unrecorded observations rather than documented supervision

Coroner's recommendations

1. CEO of DCS should implement extensive training program to ensure staff understand responsibilities under revamped SOP1
2. Improve communication and dialogue between DCS and PHS staff for at-risk prisoners; move beyond mechanistic exchange to meaningful information sharing
3. Adopt and pursue safe-cell principles throughout South Australian prisons as a matter of urgency
4. Cell-sharing should receive specific consideration during admission/screening process for Aboriginal prisoners, particularly remandees
5. CEO of DCS should ensure Adelaide Women's Prison is managed to same standards as other South Australian prisons, including discontinuation of unrecorded observations and implementation of all recommendations from Royal Commission into Aboriginal Deaths in Custody