Finding into death of Timothy Casey

Contributing factors

• Failure to respond to psychiatric referral for Acute Assessment Unit admission despite evidence of psychosis and suicidal ideation
• Inadequate assessment and documentation of declining mental state at Melbourne Assessment Prison
• Inappropriate downgrade of suicide watch rating by non-clinically qualified psychologist without formal risk assessment
• Failure to monitor psychiatric appointments or follow-up on failed consultations
• Inadequate medication management including absence of antidepressant and drug withdrawal medication
• Poor cell design with accessible ligature points in Scarborough South unit
• Lack of caseworker involvement and support in general prison population
• System failures in communication between Melbourne Assessment Prison and Port Phillip Prison regarding risk status
• Overcrowding and inadequate staffing in reception unit
• Prisoner frustration regarding unconfirmed psychiatric appointments
• Untreated withdrawn mental state of undiagnosed cause

Coroner's recommendations

1. Discharge notes for all MAP prisoners discharged from Unit 13 or Acute Assessment Unit for psychosis/suicide/self-harm should be prepared by Consultant Psychiatrist, Psychiatric Registrar, or Psychiatric Nurse (with review by duty Registrar or above), received and acknowledged by SASH officers and the RRT at receiving prison
2. Psychiatric nursing staff should provide accurate present P and S assessments based on clinical presentation, not strategic considerations regarding prisoner throughput
3. Withdraw stipulation from Reception Summary form restricting psychiatrist referral for assessment/medication review to P1/P2 classified prisoners only
4. Improve training of Forensicare psychiatric nursing staff on identification of fluctuating mental state in prisoners with documented suicidal history and importance of seeking advice upwards
5. Office of Corrections Services Review to undertake comprehensive review of conditions at Scarborough South and similarly designed units at PPP; unless structural changes are introduced, Commissioner of Corrections should suspend housing of 'at risk' prisoners (those with P or S3 rating within previous 21 days) in unrenovated cells
6. OCSR to review staffing arrangements at Scarborough South Unit to determine if levels permit appropriate duty of care
7. OCSR to review training at PPP regarding: role of caseworkers and backup caseworkers, purpose and recording of 'meaningful conversations', identification of SASH risk issues, and proper minute-taking in RRT meetings reflecting divisions of view
8. Formally adopt DOJ submission that: (a) at least 24 hours between each suicide rating downgrade; (b) each downgrade supported by formal risk assessment by appropriately qualified mental health professional; (c) RRT endorsement prior to rating change; (d) no downgrade at new prison location without formal assessment and RRT endorsement
9. Full clinical review with findings recorded on properly developed risk assessment tool should be sought and documented before presentation to RRT, and recommendation should not go before RRT unless analysis recommends downgrade
10. Amend Operational Instruction 107 to reflect proper ordering of clinical review before RRT presentation
11. Pacific Shores and St Vincent's Corrections Health develop protocols recognizing drug substitution medication as medical rather than administrative issue, allowing early intervention when medically indicated without rigid waiting list adherence; duty medical officer should verify prisoner drug history and medical reviews should drive decision-making on medication provision timing
12. Only psychologists with clinical psychology endorsement from Psychology Board of Australia should undertake suicide risk assessment evaluations in MAP and PPP
13. Commissioner of Corrections Victoria amend Directive to reflect that only clinically endorsed psychologists undertake specific risk assessment work
14. Both Corrections Victoria and Justice Health ensure only those with clinical psychologist Board endorsement are contracted for suicide/self-harm risk assessment work in Victorian prisons
15. Medically qualified specialist staff under Chief Psychiatrist be invited to undertake periodic visits to MAP and PPP to support mental health provision for at-risk prisoners