Case Number: 2022/00375404
Date of Findings: 2 May 2025
Magistrate: Deputy State Coroner, Harriet Grahame
CORONIAL LAW – mandatory inquest – death of a First Nations man in custody – was custodial health care adequate – access to and use of unprescribed medication – access to drug and alcohol programs in custody – head-checks - compliance with serious incident response and reporting protocols and procedures – recommendations
Responses
| Recommendations to |
Response |
|---|
| Commissioner of Corrective Services NSW |
Awaiting |
| Minister for Health |
Awaiting |
Recommendations
To the Commissioner of Corrective Services NSW (CSNSW)
- CSNSW review its written procedures and training concerning the confirmation of an inmate’s physical wellbeing during the conduct of “head-check” procedures having regard to the findings made in this Inquest. This extends to:
- Reviewing Custodial Operation Policy and Procedure 5.3 – Musters, Let-go and Lock-in, to provide more detailed instruction about how an officer is to confirm an inmate’s physical wellbeing during head-check. That includes ensuring clearer instruction as to whether a verbal and physical response is required from the inmate and how the officer can satisfy him or herself.
- Reviewing the sufficiency of the training provided to recruits and serving officers with respect to the procedure referred above in (a) and conducting refresher practical training for all custodial staff who conduct head-checks on inmates.
- Reviewing the Local Operating Procedures (LOPs) that concern the conduct of headchecks / let go procedures, applicable at the Shortland Correctional Centre and other Correctional Centres operated by CSNSW, to ensure there is consistency between the LOPs, COPP 5.3 and the practices employed at those centres.
- CSNSW review its written procedures and training concerning incident response and reporting in the event of medical emergencies and/or deaths in custody. That extends to:
- Requiring the separation of each involved officers, as soon as reasonably practicable and subject to operational considerations for the safety and security of the facility, until each officer has completed and submitted his or her incident report (including providing nonexhaustive guidance as to the type of instances in which operation considerations might prevail and what other arrangements might reasonably be effected to avoid that occurring).
- Mandating that, wherever possible, involved officers are not to discuss the event with each another or be present when others are discussing the event or reviewing any video evidence or be present when that evidence is being reviewed, until completion and submission of his or her incident report.
- Requiring a senior officer to assume responsibility for managing and supervising the initial incident reporting process.
- Ensuring there is clear guidance about what constitutes a medical emergency and when the abovementioned requirements are expected to be followed.
To the Chief Executive Officer, Justice Health and Forensic Mental Health Network
- Justice Health examine the arrangements and resourcing regarding the wait times for Drug and Alcohol assessments and reviews with the aim of reducing wait times.
