Finding into death of Chao Liang Mai

Contributing factors

• Classification error: medium-security rating not entered into electronic system, resulting in incorrect maximum-security placement
• Failure by Sentence Management Division to communicate classification correction to receiving prison
• Incomplete prisoner induction processes (Day of Arrival Checklist and First Night Program not completed)
• Accessible ligature point in smoke detector (via manipulation with metal fork)
• Language barrier limiting communication and support
• Proximity of classification correction to death (potentially psychological precipitant)
• Recent stressful events: arrest, police custody, prison reception

Coroner's recommendations

1. That the Sentence Management Division update the Sentence Management Manual to include processes for responding to discrepancies between a prisoner's security rating and the classification of the receiving location, including: (a) how SMD staff expediently rectify classification issues when they cannot contact staff who completed the PRSA; and (b) who from the receiving location SMD should inform of the outcome of prisoner classification reviews and the timeframe in which this must occur. [Corrected Victoria has since made required amendments]
2. That RCC's General Manager incorporate its prisoner reception processes into its annual internal audit schedule as part of GEO's Governance, Risk and Compliance Framework. [GEO has since acquitted this recommendation]
3. That Corrections Victoria provide JARO with quarterly updates on progress against smoke detector replacement works across the public system. [Replacement works were completed as of 10 August 2022]