Finding into death of Jayson Peter Hawkins

Contributing factors

• inadequate control of plastic bag access in high-risk unit
• non-compliance with procedures restricting access to plastic bags on level 5
• lack of randomisation of observation timing making observations predictable
• insufficient documentation in prisoner Individual Management Files

Coroner's recommendations

1. Prison General Managers ensure prisoner IMP files contain copies of properly authorised Separation Orders and Long-term Management Plans
2. Melbourne Assessment Prison ensure all required paperwork for suicide and self-harm risk prisoners is attached to Individual Management Files
3. Corrections Victoria explore means for staff to make random observations to reduce predictability of regularly timed observations
4. Melbourne Assessment Prison reinforce staff requirements of Emergency Management Plan (Code Black) checklist in prisoner death incident management
5. Corrections Victoria review Director's Instruction 1.12 External Escorts to permit unconscious or incapacitated prisoners not to be strip-searched prior to medical escort and staff not to carry firearms
6. Corrections Victoria develop process to ensure prisoner next of kin and emergency contact details on PIMS are verified and kept up-to-date