Finding into death of Zoran Alic

Contributing factors

• Delayed psychiatric consultation scheduling (7 weeks instead of 30 days standard)
• Lack of routine monitoring of wait times for psychiatric appointments
• Deteriorating mental health with low mood, isolation and depression not addressed by specialist
• Recent escalation of criminal charges including rape allegations
• Fear of deportation due to lack of Australian citizenship
• Stressful legal proceedings and bail refusals
• First-time custodial experience with separation from family
• Receipt of hand-up brief disclosing additional serious allegations from further complainants

Coroner's recommendations

1. Justice Health to collaborate with Forensicare to ensure timeframe measuring how long prisoners wait for non-urgent psychiatric appointments is: (i) measured for every referral; and (ii) routinely available to the Regional Clinical Coordinator role.
2. Justice Health to collaborate with Forensicare and provide appropriate training and support regarding JCare software functionality that generates timeframe data between referral and psychiatric consultation.
3. Justice Health to review resourcing of forensic mental health services at regional prisons to enable Forensicare to achieve compliance with a prescribed timeframe for non-urgent psychiatric consultations.
4. Justice Health, in consultation with primary health service providers and Forensicare, to develop a clear process ensuring: (a) prisoners waiting for non-urgent psychiatric consultation continue to be monitored and reviewed by primary mental health service; (b) where non-urgent referral does not occur within prescribed timeframe, prisoner is re-reviewed by primary health service provider.