Inquest into the Death of Tim Alan LOOKER

Contributing factors

• ADHD untreated during imprisonment
• no medication for previously diagnosed ADHD
• Type 2 diabetes not disclosed to health providers at reception
• metformin not prescribed
• protruding bolt in cell used as ligature anchor point
• cell not ligature minimised
• missed opportunity to follow up medical records from SWMHS
• doctor admission assessment delayed beyond 90-day policy
• prisoner placed in single cell after assault with minimal peer support
• no welfare check performed during afternoon unlock on day of death

Coroner's recommendations

1. To improve the care and treatment of prisoners with previously diagnosed ADHD, those prisoners who were prescribed and using a short-acting stimulant (such as dexamphetamine) in the community at the time of their imprisonment, be given the option of having prescribed a long-acting stimulant (such as lisdexamphetamine) as an alternative medication for the treatment of their ADHD.
2. To assist the treatment of prisoners with previously diagnosed mental health issues, the Department of Health and the State Forensic Mental Health Service permit 'read-only' access to PSOLIS by prison medical officers.
3. To assist the health care and treatment of prisoners, the Department introduces a prompt on its EcHO system for staff to follow up a request for a prisoner's medical information that has not been provided within a reasonable time.
4. In order to better manage vulnerable prisoners and thereby enhance security, the Department should take immediate steps to ensure all cells in Unit 2 are either three-point or fully ligature minimised as quickly as possible.
5. In order to enhance the care of prisoners, the Department adopts across the entire prison estate the recent change made by BRP to its 'Fortnightly Security Checks' form so that prison officers are reminded of the importance to identify potential ligature anchor points in cells.