Inquest into the Death of Adam Timothy Garner

Contributing factors

• First admission to adult prison system
• Multiple concurrent stressors: serious violent offence charge, uncertain sentence, drug withdrawal, Hepatitis C diagnosis, perceived lack of family/social support
• History of impulsive behaviour and ADHD
• Masking of past suicidal ideation during reception assessment
• Unavailability of juvenile detention records at time of admission
• Medication causing drowsiness limiting observation opportunities
• Lack of early mental health professional contact
• Young age (18½ years) in adult detention environment

Coroner's recommendations

1. Ensure rapid access to juvenile detention records for young persons transitioning from juvenile to adult detention system
2. All prisoners under 20 years of age entering prison for the first time should see a member of the Forensic Case Management Team (FCMT) as part of orientation, before exposure to mainstream prison environment
3. Early non-authoritarian mental health professional contact should occur before new young admittees have extensive contact with mainstream prisoners
4. Young first-time adult prisoners should be given early opportunity to contact relatives in their first isolating hours in the new detention system, prior to contact with mainstream that may negatively influence requests for assistance
5. Clarification of the term 'at risk' in the ARMS identification system to reduce confusion among staff
6. Ensure orientation processes for new admittees occur promptly, preferably before commencing work assignments