Finding into death of Joshua Steven Kerr

Contributing factors

• failure to recognise acute behavioural disturbance from drug toxicity
• failure to apply Acute Poisoning Management Guideline
• premature cancellation of hospital escort without medical consultation
• lack of discharge summary from emergency department
• TOG directive preventing medical staff access to cell
• delayed calling of Code Black
• delay in providing emergency medical treatment after Code Black called
• lack of communication between medical and correctional staff
• lack of training in recognising and managing drug-affected prisoners
• security concerns prioritised over medical care
• failure to escalate medical concerns
• inadequate initial assessment at St John's Unit
• hierarchical culture inhibiting professional judgment

Coroner's recommendations

1. G4S and SVCHS staff receive training to recognise and manage drug affected prisoners, including ABD and drug toxicity and effects on decision-making capacity
2. SVCHS receive training about practical application of the Acute Poisoning Management Guideline
3. SVCHS staff receive training to reinforce authority and responsibility to advocate for treatment and escalate where appropriate
4. G4S TOG staff receive training about importance of consulting with medical staff prior to cancellation of medical escort
5. SVHM ED staff receive training about limitations of medical treatment in prison, benefit of communication of treatment plans with escorting staff, and importance of prompt discharge summaries
6. G4S staff receive training about circumstances when they can exercise discretion to allow medical staff to enter cell for medical treatment
7. Corrections Victoria develop and implement joint training program for correctional and medical staff to enhance mutual understanding of respective roles and encourage coordinated cooperative relationship that reduces hierarchical barriers
8. Corrections Victoria amend escort policies to provide clear guidance on roles and responsibilities for provision and documentation of transfer and discharge information
9. Health Service Provider undertake interviews with staff at PPP to identify thematic or cultural issues surrounding escalation of clinical deterioration
10. Review policy on management of deterioration in prisoner under influence or suspected of being under influence of substance
11. PPP update ABD training package to include Operational Instruction 45 and SVCHS Acute Poisoning Management Guideline
12. ABD training undertaken by all PPP custodial staff on annual basis
13. PPP amend management template to include time, date, and authorisation of directives with review timeframe
14. PPP require collaboration between Health Service Provider and TOG when completing management template
15. PPP update procedures for opening cell doors after hours to ensure preservation of life is first priority
16. Health Service Providers update mental health policies to ensure clear guidance on adequate documentation and escalation of health concerns
17. Justice Health review existing acute overdose assessment tools and implement as required