Recommendation 165

This recommendation is assigned to CSNSW and Justice Health NSW.

Recommendation

The Commission notes that prisons and police stations may contain equipment which is essential for the provision of services within the institution but which may also be capable, if misused, of causing harm or self-harm to a prisoner or detainee. The Commission notes that in one case death resulted from the inhalation of fumes from a fire extinguisher. Whilst recognising the difficulties of eliminating all such items which may be potentially dangerous the Commission recommends that Police and Corrective Services authorities should carefully scrutinise equipment and facilities provided at institutions with a view to eliminating and/or reducing the potential for harm. Similarly, steps should be taken to screen hanging points in police and prison cells.

Context

Recommendation 164 is directed at ensuring that police and prison authorities reduce the risk of foreseeable harm to inmates by reducing access to potentially dangerous equipment.

Detail of implementation

Screening of hanging points

CSNSW uses a risk-assessment approach to ensure inmates with the highest level of need are managed using the least restrictive mode of care. Starting with a Justice Health & Forensic Mental Health assessment that indicates risk of self-harm or risk of suicide at the first point of arrival, and then uses a multidisciplinary team approach. Safe cells are used wherever possible for inmates at particular risk of self-harm or suicide – with a focus on active engagement instead of static observation.

In NSW there over 12,000 cells, the majority of which were constructed prior to the development of anti-ligature design standards. Removing every hanging point would be cost-prohibitive and as noted within the report, may result in a prison environment which is so oppressive that suicide attempts are more likely.

CSNSW remove obvious hanging points in cells as capital funds become available. Funds are allocated on an annual basis and in FY21/22 $6M was allocated for the removal of obvious hanging points. Funds are prioritised on the basis of risk. 

CSNSW will continue to seek capital funds to continue the removal of hanging point in cells in future years. 

Prison Bed Capacity Adjustment Program

Owing to the age of many correctional centres there are significant design challenges in eliminating all hanging points in cells.  Since 2016, the Prison Bed Capacity Program (PBCP) and the Clarence Correctional Centre public private partnership delivered a total of 2,988 new maximum-security cells designed to anti-ligature design standards. 

In 2019/20, 411 obsolete cells were retired under the Prison Bed Capacity Adjustment Program.

In 2021/22, obvious hanging points were removed in 190 cells at Long Bay and 38 at the Metropolitan Remand and Reception Centre replacing cell doors, grills, beds, basins and tapware.

Following a death in custody in Tamworth Correctional Centre in 2017, high level hanging points were removed from cells. Additional refurbishment work to address low level hanging points occurred in 2021/22 to further improve the safety of these cells, noting the difficulty of undertaking these works in a heritage correctional centre which is over 140 years old.

For FY 2022/23 CSNSW was allocated a further $6 million of capital funds to address hanging points in cells.  A priority program of works for the new funding allocation is currently being established.  Funds are allocated based on risks and operational constraints.

Managing at Risk Inmates

Custodial Operations Policy and Procedure (COPP 3.07) requires any staff member who determines that an inmate may be at risk of suicide or self-harm to immediately notify the Officer in Charge (OIC).

The OIC must then assess the risk and develop an Immediate Support Plan (ISP) appropriate to the level of risk, consistent with the principle of least restrictive care.

The OIC must also record the mandatory notification and details of the ISP in the Offender Integrated Management System (OIMS), including reporting the incident via the Incident Reporting Module (IRM) and recording an alert and case note. The OIC must also notify JH&FMHN staff (if on-site) and provide them with a copy of the mandatory notification form (MNF) and the ISP and make a case-note in OIMS recording the name of the person who was notified. If no JH&FMHN staff are on site:

• the After-Hours Nursing Manager (AHNM) must be notified (for correctional centres only)
• the CESU and Placement Officer must be notified (for Police/Court Cells only).

An ISP may be reviewed and updated at any time in response to changing circumstances, such as a transfer from one location to another. In a police/court cell complex, the OIC must prioritise the transfer of the at-risk inmate to a correctional centre. In a correctional centre, the OIC must ensure that the Risk Intervention Team (RIT) Coordinator is informed as per local procedures.

All correctional centres must have an identified RIT Coordinator, as well as a relief RIT Coordinator. The RIT is a multidisciplinary team which must include a JH&FMHN staff member. Police/court cell complexes do not operate a RIT. Amber Laurel is considered a police/court cell complex for the purpose of this policy and procedures.

The RIT convenes to formulate a management plan in response to a notification of an inmate at risk of suicide or self-harm. This considers the inmate’s presentation and inmate needs and the resources available to the centre. Each inmate requires an individualised approach to intervention, taking into consideration:

• gender
• cultural needs
• age
• cognitive and/or mental health impairments.

The management plan must be recorded and communicated to all staff involved with the management of the inmate.

Detailed information about identifying and evaluating risk of suicide and self-harm is contained in:

• Risk factors for consideration: Reference guide
• Inmate interview questions to further evaluate risk.

Justice Health NSW input

Justice Health NSW are supportive of this recommendation and follow Work Health Safety legislation and policy, and Safe Work Practices to minimise risk to patients and staff in custodial settings. This includes minimising risk of misuse, harm and self-harm of equipment essential for provision of services. Justice Health NSW are involved in equipment safety checks, reducing and removing hanging points, storing fire extinguishers and oxygen tanks outside of wards, ensuring safety of brackets and fire training to prevent misuse. Where equipment is identified as hazardous it is stored and locked away.

Evidence

Custodial Operations Policy & Procedure 3.07 – Management of inmates at risk of self-harm or suicide (PDF, 2.3 MB)