Inquest into the Death of Bradley James Raymond STINSON

Contributing factors

• metastatic pancreatic cancer
• arteriosclerotic cardiovascular disease
• pulmonary thromboembolism
• long history of heavy smoking
• long history of alcohol dependency
• advanced age with pre-existing comorbidities

Coroner's recommendations

1. Department, Serco and Ventia should ensure compliance with COPP 12.3 section 5.3 regarding restraints on terminally ill prisoners admitted to hospital
2. Restraints should not be applied to prisoners classified as Stage 3 or Stage 4 terminally ill unless an adverse EMRA specifically justifies them
3. Operations Managers should have access to the terminally ill register or obtain terminal illness status by consulting with prison health services before completing EMRAs
4. EMRAs must document clear justification and rationale when restraints are deemed necessary as exceptions to the usual prohibition
5. Medical staff should be consulted in all risk assessments for seriously ill prisoners being transferred to hospital
6. Question 3.5 of EMRA (consultation with health services) should serve as a reminder to assess terminal illness status
7. The Department should enhance risk assessment tools to include: explicit consideration of significant medical conditions/mobility issues; documented justification where restraints are required; 'Palliative Care' as a transfer reason; checkbox asking if prisoner expected to return to prison
8. Ventia should review Standard Operating Procedures to provide specific consideration of medical condition/mobility issues under COPP 12.3 section 5.3.1
9. All relevant personnel should be reminded of the 'Guiding Principles for Corrections in Australia, 2018' requirement that transport of persons in custody be 'conducted in a safe and humane manner, taking into account the dignity of the person being transported'
10. All personnel should be reminded that prisoners are to be transported in a manner that meets individual needs, ensures self-respect and privacy