Finding into death of Adam Sasha Omerovic

Contributing factors

• Failure to review P1-classified prisoner by psychiatrist or psychiatric registrar despite protocols requiring such review
• Brief 'here and now' mental state assessments by RPNs instead of longitudinal psychiatric evaluation
• Systemic diversion from established protocols due to resource constraints and throughput pressures
• Incomplete information transfer: prior ITO, suicide threat to prison officer, prior psychiatric reviews, and collateral information not available to reviewing RPNs
• Premature transfer from protective Muirhead cell (48 hours) to non-BDRP compliant general prison cell without psychiatric review
• Placement in non-BDRP compliant cell with multiple hanging points despite high suicide risk classification
• Absence of psychiatrist involvement in medication and diagnostic decisions
• Informal oral directives from senior psychiatrists circumventing written protocols
• Prisoner's rational presentation leading to underestimation of risk by non-specialist staff
• Inadequate collateral information collection and communication between assessment points
• Resource limitations: insufficient psychiatrist hours, limited BDRP-compliant cells at time of death

Coroner's recommendations

1. Forensicare seek additional funding for one full-time equivalent psychiatric consultant (or two part-time) at MAP, specifically to review and medically manage all P1 and P2 classified prisoners (psychotic or not) until safe transfer from Unit 13 and BDRP-compliant cells
2. Arrangements be made for MAP Forensicare staff to visit and review recently renovated BDRP-compliant cells so they are fully aware of changes and conditions
3. Arrangements be made for MAP Forensicare staff to visit Port Phillip Prison's Scarborough South Reception Unit to understand conditions in non-BDRP compliant cells into which at-risk prisoners may be transferred
4. Current P1 classification criteria be extended to include prisoners for pre-sentence/pre-trial psychiatric reports at AAU; review whether such prisoners can be safely detained in BDRP-compliant cells adjacent to Unit 13; all other P1 prisoners with serious psychiatric conditions be referred directly to AAU or adjacent BDRP unit for assessment and provisional diagnosis by nurse practitioner under consultant supervision or psychiatric registrar; all P2 prisoners be referred for medication review; and all Forensicare staff receive ongoing instruction on admission screening and Muirhead cell review including guidance on collateral information collection