Finding into death of Brian Richard Pope

Contributing factors

• major depressive disorder with chronic suicidal ideation
• alcohol use disorder
• history of substance abuse
• learning disability (dyslexia) contributing to low self-esteem
• social isolation and anxiety
• lack of timely collateral information from recent hospital admission
• COVID-19 quarantine procedures limiting quality of reception assessment
• assessment conducted through cell trap door with face masks
• prisoner did not disclose suicidal thoughts in prison
• cancellation of welfare checks after initial assessments despite recent psychiatric history

Coroner's recommendations

1. DJCS Secretary, in conjunction with Justice Health, Corrections Victoria and any new Health Service Provider at MRC: Arrange for face-to-face reception assessments for quarantine patients
2. DJCS Secretary, in conjunction with Justice Health, Corrections Victoria and any new Health Service Provider at MRC: Develop a policy and processes for the timely acquisition of collateral information to assist in risk assessment and formulation of care plans
3. Justice Health oversee Health Service Providers in Victorian prisons developing detailed procedure for collection and storage of collateral information during reception health assessments setting out staff roles and responsibilities
4. Collateral information procedure must include requirement to verify substance use (type and quantity) in consistent manner with prisoners at time of assessment
5. Collateral information procedure must require staff to make appropriate efforts to collect information from family members to inform mental health assessments
6. Collateral information procedure must set out approach for gathering and using information about prisoners' offences and impact on relationships and future planning
7. Collateral information procedure must provide guidance on actions following review of collateral information including review of prisoner's risk rating and mental health care plan
8. Collateral information procedure must ensure actions taken following review of collateral information are recorded in JCare
9. Compliance and effectiveness of collateral information procedure must be audited by Health Service Providers within six months of endorsement
10. Health Service Providers develop procedure to support staff to escalate concerns about assessments conducted via cell trap to ensure face-to-face assessments occur
11. Department of Justice and Community Safety undertake review of current mental health assessment tool to ensure it meets contemporary practice