Coroner's Finding: McLEOD Ian

Contributing factors

• Failure to perform mental state assessment on admission to prison despite clear indication of depression
• Failure to complete Prison Stress Screening Form on admission
• Failure to conduct Admission Clinical Record interview
• Inadequate monitoring of alcohol withdrawal
• Antidepressant medication (Aropax) not administered on day after admission
• Loss of critical clinical information during verbal shift handovers
• Obvious hanging point in observation cell
• Inadequate surveillance of at-risk prisoner in observation cell
• Late evening admission to prison outside normal procedures
• Breakdown in communication between custodial and medical staff regarding risk assessment

Coroner's recommendations

1. That all General Managers ensure that appropriate documented handover procedures exist for the transfer of information concerning any prisoner (not limited to at-risk prisoners or those in infirmaries)
2. That the hanging point in the prison cell be removed by removing the door and replacing it with privacy curtains designed to not provide hanging points
3. That all infirmaries be assessed as part of a comprehensive review of cells controlled by the Department for Correctional Services in accordance with safe cell project principles
4. That roles and responsibilities of all involved agencies (SAPOL, DCS, Group 4, PHS) be clarified with development of appropriate procedures for transfer of prisoners between country areas and the city, and between institutions
5. That legal advice be sought regarding the Department's responsibilities in taking custody of prisoners remanded by courts, including those receiving in-patient care in hospitals, and receiving prisoners outside of regulated hours