Inquest into the Death of Hendrik Jan Groothedde

Contributing factors

• chronic suicidal ideation and personality disorder
• failure to act on discharge summary identifying ongoing suicide risk
• inadequate integration of clinical information between separated Health Services and Prison Counselling Services
• premature removal from at-risk monitoring (ARMS) on 3 January 2003
• inadequate continuity of psychological review and monitoring
• fragmented medical records across multiple services
• absence of documented risk management plan after suicide attempt
• ARMS system focused only on acute rather than chronic risk
• additional unidentified prison stressors (drug transaction)
• medication non-compliance and involvement in prison medication transactions

Coroner's recommendations

1. Implement emphasis on integrated risk management plans with plans widely and easily available to all those involved in care of a prisoner, with designated access levels
2. Give adequate attention to all risk factors balancing objective/static factors against subjective/fluid self-reporting, taking a holistic approach to prisoner health and welfare
3. Enhance ARMS and PRAG system to record reasons for and rationale involved in changing a prisoner's ARMS status in medical files
4. Enhance ARMS system to show a case management approach for individual prisoners as originally envisaged
5. Department of Justice consider reallocation and provision of additional resources for Prison Counselling Services and Mental Health Services to allow for wider and more effective monitoring of prisoners at chronic risk of self-harm
6. Prison Administration recognise that for a healthy prison environment there must be emphasis on problem solving not problem deflecting, with integrated coordination between Health Services and Prison Counselling Services