Finding into death of Michael Scott Wyly

Contributing factors

• suicide and self-harm risk not adequately managed post-discharge from acute assessment unit
• inadequate documentation of psychiatric assessment and risk rating downgrades
• poor communication between mental health clinicians and sentence management unit regarding cell placement
• single cell placement contradicting psychiatric assessment noting cell mate was beneficial
• insufficient structured follow-up post-discharge from acute assessment unit
• lack of formal handover communication channel with family members
• cell design vulnerability—air vent holes accessible as ligature anchor point

Coroner's recommendations

1. The Office of Corrections should appoint a Ward clerk for all prisoners discharged from either Unit 13 or the Acute Assessment Unit to serve as a readily identified conduit for potentially vital information to be conveyed to mental health clinicians.
2. Forensicare should provide a discharge sheet to mental health clinical staff upon discharge from Unit 13 or the Acute Assessment Unit, containing a summary of the prisoner's history and relevant information.
3. Endorse recommendations from the Office of Correctional Service Review report regarding prisoner welfare.
4. Expedite completion of Building Development and Review Project (BDRP) cell safety upgrade works at Melbourne Assessment Prison to prevent ligature points in mainstream accommodation.