Inquest into the Death of Barry Matt STUART

Contributing factors

• cessation of olanzapine without psychiatric review
• severe shortage of forensic psychiatry services in prisons
• delayed psychiatric appointment (scheduled 2 weeks post-death)
• psychological dependence on sedative effects of medication
• broken relationship with ex-partner
• depression and history of previous suicide attempts
• poor sleep on cessation of olanzapine medication
• lack of alternative sedation provided following medication cessation
• mental health nurse decision to cease medication in context of resource limitations

Coroner's recommendations

1. Department of Corrective Services should invest significantly more resources in ensuring prisoners are given regular access to psychiatrists
2. Overall emphasis should be placed on providing a more holistic approach to mental health care in prisons
3. Mental health nurses should not make decisions about ongoing medication requirements without medical officer advice (GP or psychiatrist)
4. GPs prescribing antipsychotics prior to psychiatric review should record a working diagnosis and continue medication until psychiatric review unless good indication to cease; if ceasing, documentation should be meticulous
5. Department should develop a formal 'missed medication' or 'refusal of medication' policy providing clear procedures when prisoners refuse medication
6. GPs engaged with prison health services should be encouraged to undertake extended mental health skills training
7. Steps should be taken to deliver the full FTE consultant psychiatry required for appropriate coverage across prisons