Coroner's Finding: BROOKS Neil James and FOSTER Tracy Jayne

Contributing factors

• inadequate mental health assessment before transfer to remand centre
• revocation of detention order with insufficient justification
• failure to provide comprehensive medical notes to remand centre
• cursory briefing of remand centre staff about psychiatric risk
• placement in single-cell accommodation despite suicidal ideation
• absence of self-harm notification forms on case file
• lack of high-risk assessment team process (implemented only in 2004)
• no yellow sheet or yellow plaque system in place
• possible medication non-compliance not detected
• communication barriers between psychiatric and custodial services
• underlying chronic depression with acute deterioration triggers

Coroner's recommendations

1. Department for Correctional Services should consider introduction of measures to improve communication and information exchange between psychiatric and custodial services, including relaxation of confidentiality obligations in best interests of prisoner
2. Department of Health should consider similar measures regarding prison health service operations and statutory codification of prison health service existence and role
3. Consider statutory codification of Prison Health Service to clarify roles, enable modified health-prisoner relationships recognising prison system realities, and provide relaxed confidentiality provisions
4. Consider system to ensure medication refusal by prisoners is reported to treating medical practitioner for assessment of whether forced administration is necessary
5. Custodial staff may have authority and duty to administer prescribed medication by duress if necessary when medically necessary for prisoner welfare, without further Mental Health Act authorisation
6. Implement mandatory referral to treating medical practitioner when prisoners refuse prescribed medication
7. Improve exchange of information between custodial system and Prison Health Service while respecting privacy obligations
8. Ensure prisoners at suicide risk are identified and tracked across system changes and staff movements