Inquest into the Death of Scott Davidson

Contributing factors

• Paranoid schizophrenia with known psychiatric history
• Recent sentencing to 9 years imprisonment causing psychological distress
• Failure to provide immediate psychiatric assessment after sentencing despite judicial recommendation
• Medical file not transferred to Casuarina Prison in timely manner
• Exposure to multiple suicide-related stressors within 2.5 days: witnessing cellmate self-harm incidents and discussions about suicide methods
• Inappropriate cellmate placement with Jose within hours of Jose's exposure to another prisoner's self-harm
• Inadequate cell checks by night officer (Hill) who failed to observe deceased during 3:00am check
• Lack of adequate supervision and mental health assessment following self-harm incident on 3 June
• Prison staff confusion about whether deceased had been assessed by mental health professional after 3 June incident

Coroner's recommendations

1. Warrants of Commitment be amended to include provision for recommendations made by the sentencing Judicial Officer regarding appropriate medical review of prisoners after sentencing
2. Prisoners who have been on remand be returned to familiar surroundings immediately after sentencing until the effect of their sentence has been assessed
3. A prisoner's medical file be transferred in a timely manner (within 12 hours) when a prisoner moves prison or is readmitted to the prison system after a period of absence
4. Until a prisoner's medical file has been reviewed by an appropriately skilled medical officer, a prisoner newly sentenced for a significant period be afforded special observation by Senior Unit Officers who consciously afford those prisoners special regard
5. Prisoners with a known psychiatric illness or personality disorder be appropriately assessed as soon as possible after an incident that is an obvious stressor
6. There be ongoing education of prison officers to keep them alert to indicators for self-harm and prevent desensitisation to the environment of incarceration
7. Cell check procedures be improved to ensure officers consciously look for evidence of a body and its condition, not merely anything out of the ordinary