Finding into death of Noel Thomas

Contributing factors

• mental health conditions including depression and bipolar affective disorder
• history of suicide attempts and self-harm
• rapid de-escalation of suicide risk ratings
• cancelled psychiatric appointment not rescheduled
• inadequate continuity of mental health care across prison transfers
• lack of access to interstate medical records
• prisoners' ability to conceal suicidal intent after risk assessment
• ephemeral nature of risk assessments
• lack of structured step-down protocols when transitioning from high-risk to standard observation
• lengthy prison sentences and expected extradition contributing to acute distress

Coroner's recommendations

1. Secretary to Department of Justice and Community Safety investigate viability and utility of centrally and remotely monitoring vital signs of prisoners assessed for suicide or self-harm risk, including extent to which such monitoring may reduce need for S1 prisoners in Muirhead cells
2. Prison authorities explicitly consider whether reasonable alternatives exist before transferring a prisoner between prisons
3. Victorian prisons have timely access to interstate medical records of prisoners in custody
4. Secretary facilitate step-down management plan for prisoners whose S rating reduced from S3 to S4, as foreshadowed in JARO Report
5. Secretary instigate auditing of utility and effectiveness of referral process for prisoners struggling with issues to Offending Behaviour Programs
6. Secretary ensure clear line of responsibility in place for rescheduling cancelled medical appointments in Victorian prisons, with auditing for efficient and effective operation