Coroner's Finding: GILL Andrew Stephen and SCHAER Simon

Contributing factors

• failure of police to communicate suicidal ideation and diary entries to correctional services
• incomplete Prisoner Screening Form - critical sections not filled out
• failure to complete Information for Prisoner Escort section of PD331
• entrenched practice at Elizabeth police station of not completing critical risk assessment sections
• lack of electronic information-sharing system between SAPOL and DCS
• placement of high-risk prisoner in general population unit with access to mezzanine balcony
• insufficient time allocated for medical assessment of newly admitted prisoners
• lack of formal procedure for family members to report concerns about prisoner welfare
• architectural design of accommodation units allowing access to mezzanine floors and balconies from which falls were possible
• no post-Gill directive to staff to monitor mezzanine behaviour

Coroner's recommendations

1. Establish and maintain ongoing working group between Commissioner of Police, Chief Executive DCS, General Manager ARC, GSL, Courts Administrator, Chief Executive Department of Health, Prison Health Service and Aboriginal community representative to review procedures for transfer of information between custodial entities regarding prisoner self-harm risk
2. Establish electronic system through Justice Information System or other medium enabling custodial entities to immediately access information concerning prisoner self-harm risk posted by other entities
3. Continue to develop and improve formal procedures for registration, acknowledgment and action upon expressions of concern for prisoner welfare from families, friends and associates
4. Commissioner of Police remind members of mandatory nature of General Orders and consequences of departure
5. Commissioner of Police ensure all custody officers aware of need to continually monitor and document evidence relevant to prisoner self-harm risk
6. Commissioner of Police remind officers of possible need for psychiatric or medical examination of prisoners whilst in police custody
7. Enclose mezzanine floors and staircases in accommodation units of Adelaide Remand Centre with bars to ceiling
8. Apply for funding for mezzanine enclosure with bars to ceiling
9. Ensure medical practitioners examining newly admitted prisoners afforded more time
10. Ensure social workers interviewing newly admitted prisoners afforded more time