Finding into death of Finding Cain Douglas Ernest Hutchinson

Contributing factors

• Ingestion of drug-filled balloon that ruptured in gastrointestinal tract
• Inadequate visitor intelligence alert assessment procedures
• Failure to apply historical intelligence regarding visitor contraband risk
• Lack of targeted telephone monitoring for drug-related communications
• Inadequate drug interdiction procedures during contact visits
• Potential prisoner vulnerability to intimidation for drug procurement

Coroner's recommendations

1. Corrections Victoria amend relevant policies to clarify required processes and records for assessing nominated visitors with PIMS visits alerts
2. Corrections Victoria seek assurance from Port Phillip Prison that barrier control infrastructure and processes reflect required standard
3. Corrections Victoria seek assurance from Port Phillip Prison that supervision and monitoring in the prison's visits centre achieve required standard
4. Port Phillip Prison update relevant policies to require reception staff forward all applications from visitors with intelligence alerts to the Prison Intelligence Unit for further assessment
5. Implement requirement that when a visitor uses bathroom or baby-changing facilities during contact visit, the visit must proceed as non-contact visit thereafter
6. Record the manner in which PIMS visitor flags are actioned in the visits module for audit and accountability