Inquest into the death of Alfonso Ceniccola

Case number: 2021/00261563

Date of Findings: 24 February 2025

Magistrate: Elizabeth Ryan, Deputy State Coroner

CORONIAL LAW – death in custody – care and treatment – requirements and frequency of physical observations – policies, procedures, and training applicable to supervision and management of inmates in the Acute Care Management Unit.

Responses

Recommendations

Commissioner of Corrective Services NSW

1.  That consideration be given to implementing a formal induction process for all officers working in the Complex Placement Unit at the Metropolitan Remand Reception Centre, which has replaced the Acute Care Management Unit. The induction should emphasise to officers the importance of familiarising themselves with the requirements of Risk Intervention Team management plan and other information about inmates, particularly regarding the requirements and frequency of physical observations.