Finding into death of Naser Vukovic
Deceased
Naser Vukovic
Demographics
42y, male
Date of death
2016-06-08
Finding date
2022-04-04
Cause of death
Incised injury to the neck resulting in exsanguination and air embolism
AI-generated summary
Naser Vukovic, a 42-year-old prisoner with severe psychotic symptoms and dual P1/S3 risk ratings, died by self-inflicted neck laceration in Melbourne Assessment Prison on 8 June 2016. Despite two prior self-harm incidents with razor blades in April and May 2016, and clinical assessment recommending acute assessment unit admission, he remained on a waiting list and was housed in a mainstream unit with unrestricted access to razor blades. The coroner found that while psychiatric care followed policy, the system failed operationally: the acute assessment unit had inadequate capacity (16 beds for a prison population needing 81), making the policy framework unviable. Clinicians did not restrict access to means despite his documented history of razor-blade self-harm. Key failures included lack of family communication despite consent, medication non-adherence not addressed in clinical notes, and absence of intermediate-level units between mainstream housing and restrictive observation cells to manage high-risk patients safely.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Inadequate bed capacity at Acute Assessment Unit (16 beds vs estimated need for 81 prisoners)
- Policy non-compliance: P1/S3 prisoner housed in mainstream unit instead of Acute Assessment Unit
- Unrestricted access to razor blades despite prior self-harm with same method
- Lack of documented risk management plan addressing access to means
- Medication non-adherence (risperidone) not adequately addressed
- Absence of intermediate-level units between mainstream and observation cells
- Inadequate family communication despite prisoner consent
- Extensive waitlist for acute assessment unit (16-20 prisoners waiting)
Coroner's recommendations
- Corrections Victoria and Justice Health ensure Risk Review Teams document consideration of access to means (razor blades, sharps) when placing prisoners in BDRP cells as part of Risk Management planning
- Corrections Victoria and Justice Health update Melbourne Assessment Prison 'At Risk' Local Operating Procedures to remove impractical references to restricting sharps access in mainstream units, reflecting operational reality
- Corrections Victoria and Justice Health investigate and develop an 'in-between' unit within Victorian prison system where access to self-harm means (razors, sharps) can be practically restricted for high-risk prisoners with self-harm history
- Corrections Victoria implement system to ensure prisoners are aware of right to consent to health information disclosure; provide consent forms at reception and during visits; make forms readily available and place on prisoner records
- Justice Health develop system with Forensicare for prisoners to nominate support persons for non-legal advocacy in mental health care, similar to Mental Health Act nominated person provisions
- Department of Justice and Community Safety review mental health resources at Melbourne Assessment Prison including: (a) resources required for contemporary assessment and care in high-acuity setting; (b) impact of finite Thomas Embling Hospital bed demand on prisoner housing decisions
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