Coroner's Finding: BLUNDEN Shane Rene

Contributing factors

• failure to transfer risk assessment information from Adelaide Remand Centre to Yatala
• inadequate prison stress screening at admission (score of 7 instead of 9)
• erroneous recording of previous overdose and scars during admission assessment
• failure to access Justice Information System records showing prior warnings of suicide risk
• non-consolidation of Adelaide Remand Centre Prison Health Service file with Yatala file
• inadequate liaison between DCS and PHS staff at admission
• placement in single-cell accommodation in F Division despite high self-harm risk
• accommodation in cell with known ligature point (ventilation grille)
• infrequent observation in F Division (only at 11:25am and 3pm)
• removal from HRAT regime at ARC not considered relevant by Yatala staff
• poor understanding of JIS access by admitting officers

Coroner's recommendations

1. Department for Correctional Services continue identifying and eliminating hanging points from all South Australian correctional institutions, particularly replacing ventilation grilles and air-conditioning vents with anti-ligature alternatives
2. Chief Executive of Department for Correctional Services identify and appoint dedicated, thoroughly trained correctional officers specifically for prisoner admission with full unrestricted JIS access
3. Chief Executive of Department for Correctional Services ensure all documentation received at prisoner arrival is examined by admitting officer and copies placed in case management file and provided to Prison Health Service; no documents removed from admission bundle; create detailed inventories by SAPOL and DCS
4. Chief Executive of Department for Correctional Services ensure enquiries at admission of prisoners under 20 years regarding juvenile justice system involvement and self-harm risk
5. Chief Executive of Department for Correctional Services ensure all newly admitted prisoners under 20 years are assigned a case officer regardless of expected length of imprisonment or remand status
6. Continued requirement for newly admitted prisoners to be in shared accommodation within first seven days with renewed prisoner stress screening at conclusion of seven day period
7. Chief Executive of Department for Correctional Services ensure no prisoner placed in single accommodation containing obvious hanging points, particularly ventilation grilles
8. No prisoner removed from HRAT regime should be immediately placed in single cell accommodation
9. Chief Executive of Department for Correctional Services ensure fresh prisoner stress screening when placing prisoner in single cell accommodation with full JIS enquiries
10. Chief Executive of Department for Correctional Services ensure F Division prisoners initially accommodated in double cell accommodation
11. Chief Executive of Department for Correctional Services ensure complete immediate access to all information gathered about prisoner by DCS and within juvenile justice system
12. Chief Executive of SA Health ensure proper procedures for conveying Prison Health Service files between correctional institutions
13. Chief Executive of SA Health establish electronic database enabling Prison Health Service staff to view entire prisoner health records regardless of prior institutions or system type
14. Chief Executive of Department for Correctional Services and SA Health establish procedures enabling Prison Health Service staff to access Justice Information System, particularly regarding self-harm risk information
15. Chief Executive of Department for Correctional Services and SA Health establish procedures for information sharing between DCS and PHS staff during admission to ensure consistency of prisoner information