Inquest into the Death of Natasha Leanne Quartermaine

Contributing factors

• failure to implement ARMS (At Risk Management System) despite clear suicidal ideation
• failure to communicate risk status to supervising officers
• lack of proper briefing of medical staff on recent psychiatric history
• medication dispensing errors including omission of prescribed Clopixol and Olanzapine
• missed family visits which precipitated acute emotional distress
• incomplete psychiatric assessment by Dr C. without knowledge of recent concerning statements
• staff assumption that suicidal statements represented medication-seeking behaviour

Coroner's recommendations

1. Department of Justice should give consideration to implementing a system which would provide health centres in prisons with copies of at least pages 1 and 2 of an ARMS file immediately following the raising of the file
2. Continuation of ARMS refresher training package (noted as being developed for latter half of 2004)
3. Ensure that the first person to see an at-risk prisoner commences the ARMS process and records specific statements of risk
4. Implement proper communication protocols between FCMT, medical staff, and supervising officers to ensure risk status is communicated
5. Review procedures for medication dispensing and cross-checking medication charts against medical practitioner instructions
6. Ensure appropriate briefing of visiting medical practitioners on recent psychiatric history and ARMS status of prisoners