Inquest into the Death of Dylan Robert Green

Contributing factors

• Serious mental illness with psychotic episodes
• Previous suicide attempt and self-harm ideation
• Presence of obvious hanging points in cell
• Removal from intensive monitoring despite ongoing mental health risks
• Discontinuation of anti-psychotic and anti-depressant medication without detection
• Lack of direct communication between psychiatrist and psychology/social work team
• Inadequate community treatment order at hospital discharge
• Non-compliance with post-discharge mental health plan

Coroner's recommendations

1. The Department of Justice should take immediate action to assess cells in various prisons throughout the state with a view to identifying possible hazards such as obvious hanging points.
2. The Department of Justice should include minimisation of obvious hanging points as an instruction in the design of all cells to be constructed in the future.
3. The Department of Justice should review procedures with a view to promoting direct interaction between psychiatrists and psychologists, social workers and others involved with the monitoring of prisoners.
4. The Department of Justice should review ARMS procedures so that ARMS documentation is available at a prison where a prisoner is housed until the completion of his or her sentence.
5. The Department of Justice should review procedures to ensure that when a prisoner fails to take medication which is important to the well being of the prisoner, that failure is identified and reported to the relevant personnel.
6. The Health Department should consider having a review of the practical application of the Mental Health Act 1996 as it relates to community treatment orders with a view to determining whether community treatment orders are serving the purpose for which they were intended and, if not, whether amendment is required.