Finding into death of Matthew Aaron Condie
Deceased
Matthew Aaron Condie
Demographics
21y, male
Date of death
2007-09-27
Finding date
2015-01-30
Cause of death
upper airway obstruction and plastic bag asphyxia
AI-generated summary
Matthew Aaron Condie, a 21-year-old prisoner serving a 12-year sentence at Port Phillip Prison, died by asphyxiation using a plastic bag on 27-28 September 2007. The coroner found his death was potentially preventable due to systemic clinical and management failures in suicide and self-harm (SASH) risk assessment. Despite completion of a two-month psychiatric assessment showing chronic self-harm risk and observed deterioration in isolation, his risk status was rapidly downgraded from S2 to S3 on 27 September 2007 without considering the isolating prison environment known to worsen his mental state. Critical failures included: poor information sharing between psychiatric services, correctional staff, and psychologists; psychologists lacking access to medical records; and inadequate overnight monitoring in an isolation cell. A properly informed risk assessment with access to all available information would have maintained his elevated risk status and possibly prevented his death.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- Rapid downgrading of suicide risk status without considering isolation environment
- Placement in isolating conditions (spine of Charlotte Unit) despite known negative mental health response to isolation
- Poor communication and information sharing between clinical services and correctional staff
- Psychologist lacked access to comprehensive medical records
- Personality disorder with chronic self-harm and suicidal ideation
- Anxiety related to pending appeal
- Systemic failures in SASH risk assessment and management processes
- Lack of overnight monitoring despite at-risk status in isolation
- Inadequate structured decision-making in Risk Review Team meetings
Coroner's recommendations
- Develop a comprehensive yet accessible summary of prisoners' health information containing SASH-sensitive data, regularly updated and available to all treating clinicians
- Mandate use of such health information summaries by all healthcare providers in Victorian prisons (public and private)
- Develop and implement case management scheme for prisoners with complex medical, psychiatric, or behavioural issues, including documented SASH risks, triggers, diagnoses, and management strategies
- Review SASH processes to discourage rapid or precipitous downgrading of at-risk status, with explicit requirement that risk assessments for spine-placed prisoners address isolation effects and implement individually tailored observation regimes
- Enhance SASH risk training for correctional officers emphasizing meaningful interaction with S3-rated prisoners as a safety measure
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