Case Number: 2019/351386
Date of Findings: 15 December 2021
Magistrate: Deputy State Coroner, Magistrate Elaine Truscott
Catchwords: CORONIAL LAW – Cause and manner of death - First Nations death whilst in lawful custody of Corrective Services NSW - Hospital escort - Escape - Intent to self-harm - Risk Intervention Team treatment
Responses
| Response | Status |
|---|
| Commissioner for Corrective Services | Received (DOC, 1.1 MB) |
| Minister for Health | Received (DOC, 1.1 MB) |
Recommendations
To Corrective Services NSW:
- That CSNSW amend the “Management of Inmates at Risk of Self-Harm or Suicide” policy to require a co-ordinator of a Risk Intervention Team (RIT) review meeting to seek that a psychologist be a member of the RIT and in the event that the psychologist is unable to participate in the review meeting, provide an opportunity for the Special Programs and Activities Officer (SAPO) and/or Justice Health member of the team to consult with the centre’s psychologist or an off-site mental health service provider, prior to any determination of the RIT review team.
- A) That CSNSW amend the “Management of Inmates at Risk of Self-Harm or Suicide” policy to indicate that the RIT coordinator is required to compile and distribute a folder of specified documents to the RIT members prior to the RIT review meeting in sufficient time so that those members are informed of the matters contained therein. The documents are to include:
i. the Part 1 Mandatory Notification;
ii. prior Mandatory Notifications, Immediate Support Plans (ISP) and RIT plans;
iii. recent Offender Integrated Management System (OIMS) case notes with regard to the mental health of the inmate;
iv. any observations of the inmate in a cell made while on an ISP or a RIT; and
v. current OIMS alerts in relation to the inmate.
B) That CSNSW amend the “Management of Inmates at Risk of Self-Harm or Suicide” policy to provide that any ISP and RIT Management Plan must include written reasons as to the following:
i. the decision to place the inmate on the ISP or the RIT;
ii. the cell placement, including reasons why a less restrictive placement option, if available, is not suitable; and
iii. if a less restrictive placement option is unavailable at the time, why that option is unavailable and when, if ever, it will be available.
C) That CSNSW amend the “Management of Inmates at Risk of Self-Harm or Suicide” policy to provide the following:
i. That any ISP and RIT management plan identify in writing the names of the person/s and/or designation of office who will be responsible for the management of the inmate on the relevant shifts until the next RIT review; and
ii. that this information is provided to the inmate. - A) That CSNSW amend the “Management of Inmates at Risk of Self-Harm or Suicide” policy to provide the following:
i. That an inmate placed on an ISP is to be provided the opportunity to have telephone contact with an approved support person (approved by the governor or delegate). Such telephone contact by the inmate is to be facilitated as soon as possible - preferably within two hours - of the inmate being placed on an ISP.
ii. That a phone call from an inmate to an approved support person be facilitated at the establishment of a RIT Management Plan and upon each 24 hour extension of such plan.
iii. That a phone call from an inmate to an approved support person be facilitated at the discharge from an ISP or upon the establishment of a RIT discharge plan.
iv. The policy should clarify that any additional telephone calls to an approved support person are to be at the discretion of the officer managing the inmate.
v. The policy should make it clear that these telephone calls are not a substitute for any telephone calls for the purpose of human contact or interaction as set out in the ISP or RIT management plan or discharge summary.
B) That CSNSW amend the “Management of Inmates at Risk of Self-Harm or Suicide” policy to include that as soon as practicable following a Mandatory Notification, the managing officer is to:
i. Inform the inmate of the decision and the reasons for the Mandatory Notification Form (MNF) and the ISP components.
ii. Inform the inmate that they are entitled to have telephone contact with an approved support person. If the inmate wishes to do so, they are to provide the name and phone number of that person and once approved by the governor or delegate, a phone call by the inmate to that approved support person is to be facilitated as soon as possible (this should occur within hours of being placed on a ISP or RIT Management Plan). If the inmate does not wish to nominate a person, that should be recorded in writing.
iii. Inform the inmate that their ISP or RIT status will be subject to review within 24 hours and that they will attend the meeting of the review team to discuss their level of risk of harm and any protective factors and safeguards that can be put in place so that they could be discharged from the ISP or RIT.
iv. Inform the inmate that they can now, or at any stage whilst on the ISP or RIT, provide written consent for CSNSW staff to communicate with specified third party(ies) for the duration of or any specified part of the ISP or RIT, with that consent to indicate the parameters, if any, of information to be provided. Further, they are to inform the inmate that this will be documented appropriately in OIMS and retained with the inmate’s RIT documentation in the event that it is useful or necessary for the management and support of the inmate on the ISP or the RIT.
v. Inform the inmate that they may withdraw their consent in writing at any time and, that where there is a withdrawal of consent, that will be documented in OIMS and retained with the inmate’s ISP or RIT documentation.
vi. Provide an opportunity for the inmate to provide such consent for the duration of, or a specified part of, the ISP or RIT.
vii. Request the inmate to sign an acknowledgement that the above has been explained to them and that they understand the process. In the event that an inmate does not wish to sign, the officer should record this fact and any reasons expressed by the inmate as to why they do not wish to sign.
viii. Complete the appropriate OIMS documentation (with respect to the above) and retain the consent documents.
ix. Notify Justice Health that an inmate is on an ISP or RIT (see also, Joint Recommendation CS/JH 3).
C) That CSNSW amend the “Management of Inmates at Risk of Self-Harm or Suicide” policy to require the following:
i. each RIT review member is to sign an acknowledgement of completion of the necessary training to undertake the role;
ii. the co-ordinator is to record the time of the commencement and conclusion of the RIT review meeting;
iii. the co-ordinator is to record the time at which the inmate was in attendance at the RIT review meeting; and
iv. the completion of all sections of the forms is to be carried out with the use of the assessment guideline documents. - That CSNSW amend the following forms: Part 1 Mandatory Notification Form, Part 2 Immediate Support Plan, and Part 3 Risk Intervention Team (RIT) Management Plan, to incorporate the following (including to facilitate the changed policy set out in Recommendations CS 2 and CS 3):
i. the time at which the inmate is placed in the RIT assessment cell;
ii. the time at which the ISP is commenced and the time/s at which it is completed and/or amended;
iii. an acknowledgement to be signed by each RIT review member of completion of the necessary training to undertake the role;
iv. the times at which those adopting the contents of the form signed, and the legible names of the signator/s; and v. the time/s at which the inmate attends and departs a RIT review meeting. - That CSNSW investigate the implementation of a procedural safeguard enabling an approved third party to accompany and assist an inmate when they attend a RIT review meeting, on the basis that the third party would attend by remote facility such as webconferencing.
- That CSNSW investigate and, if practicable, establish a resource document setting out the names of First Nations elders and First Nations organisations, being those who can provide mentoring support to First Nations inmates subject to an ISP or RIT management plan. Such culturally appropriate mentorship and support is to occur whilst the inmate is on the plan. If such a resource is established, rather than restricting access to it to First Nations inmates subject to an ISP or RIT, other First Nations inmates who are struggling to adjust to their environment and situation should have free access so that they receive culturally appropriate support as needed.
- That CSNSW amend policy and procedure to:
i. Ensure that when an inmate in an assessment cell requests to see a nurse, psychologist or psychiatrist, that such request be communicated to the nurse, psychologist or psychiatrist.
ii. In the event that such person declines to attend, a written note to that effect should be made in OIMS.
iii. If a nurse, psychologist or psychiatrist declines to attend, the inmate should be provided the opportunity to make a call to the 1800 Mental Health Helpline and this should be recorded in OIMS. - That CSNSW amend its policy to require documentation in OIMS of observations by CSNSW staff of an inmate’s behaviour, progress or deterioration while placed in an “assessment cell”, with such documentation to be recorded on an hourly basis, and that there be an obligation on change of shift for there to be a verbal handover regarding the observations made about the inmate during that shift. Where competing shift duties do not permit such records to be made each hour, entries are to be made as duties permit, and an end of shift record must be made, noting the observations of the inmate during the shift. Where no verbal handover is possible, the incoming staff member should review the OIMS of any inmate housed in an assessment cell, at their earliest convenience, in relation to their presentation over the period of their placement in the assessment cell.
- That CSNSW amend its policy to require CSNSW staff to contact the on-duty Justice Health staff member if an inmate’s physical and/or mental health is observed to deteriorate while housed in an “assessment cell”.
- CSNSW is to address the use of assessment cells at Kariong Transit and Intake Centre (Kariong TIC) to ensure that they are fit for purpose. Until such time that Kariong TIC is able to provide an inmate on a RIT with access to their entitlement per cl. 53 of the Regulation for daily open air exercise, an inmate who would otherwise be housed in an assessment cell at Kariong TIC should be immediately transferred to a correctional centre which can provide for the placement option of least restrictive care whilst they are at risk of self-harm.
- That CSNSW conduct a review into the use of assessment cells to manage inmates at risk of self-harm and whether such use is consistent with adherence to the concept of least restrictive placement options. Such review should also include whether RIT Management Plans appropriately allow for diversionary activities and human interaction as contemplated by the policy, and whether appropriate mental health interventions are being provided to the inmates whilst in the assessment cell.
- That CSNSW develop a document to provide guidance and structure to officers charged with the task of monitoring and managing an inmate on a RIT in an assessment cell, so that any deterioration in the inmate’s condition can be appropriately escalated and managed and further, so that a proper record is kept of the inmate’s progress. This document is to be provided to the co-ordinator of the RIT review meeting and a copy to the manager responsible for the inmate at the time of that review.
- A) CSNSW is to develop an appropriate training module and guidelines to assist staff (including but not limited to psychologists, SAPOs and relevant senior officers) to communicate with family members who are making inquiries about an inmate’s wellbeing. That training package is to be rolled out across CSNSW correctional centres.
i. That training should include, but not be limited to:
a) that the CSNSW Family Handbook advises family members when they are 130 entitled to contact a correctional centre in order to provide information about an inmate (see Recommendation CS 13(b));
b) accepting a telephone call, ascertaining what the inquiry is, taking the name and contact details of the caller and prioritising the urgency of attending to the family’s request;
c) understanding the difference between gathering information and giving information;
d) defining what information can be given without written consent;
e) defining what information cannot be given without written consent;
f) determining an appropriate time frame within which any required written consent is obtained from the inmate;
g) the process by which such consent is to be sought and obtained, including what should be specified on the consent form;
h) documenting information provided to a family member; and
i) documenting information provided by a family member and to whom it should be given.
ii. That training should include scripts, consent forms, practical role plays and scenarios.
B) That CSNSW amend the ‘Families Handbook’ to clearly identify that a family member or support person is entitled to contact a correctional centre in order to provide information about an inmate’s medical health including mental health in urgent or important circumstances. All contact should be initially made to the Justice Health and Forensic Mental Health Network 24 hour hotline – ph: 1800 222 472, and then alternatively to the Functional Manager on duty of the correctional centre where the inmate is detained, or a SAPO on duty at that centre.
C) That as soon as practicable CSNSW send an email memorandum to appropriate staff members reminding them that family members are entitled to contact a correctional centre in order to provide information about an inmate’s medical health including mental health in urgent or important circumstances and accordingly those telephone calls should be accepted and actioned.
To CSNSW and Justice Health:
- That Justice Health and CSNSW liaise and ensure that their respective websites and the relevant part of the ‘Families Handbook’ are consistent with the following information:
i. that a family member or support person is entitled to contact a correctional centre in order to provide information about an inmate’s medical health including mental health in urgent or important circumstances; and
ii. that all contact should be initially made to the Justice Health and Forensic Mental Health Network 24 hour hotline – ph: 1800 222, and then alternatively to the Functional Manager on duty of the correctional centre where the inmate is detained, or a SAPO on duty at that centre. - That Justice Health and CSNSW convene a joint working group for the purpose of improving the current custodial mental health model of care, with specific focus on the provision of multidisciplinary, integrated, evidence-based healthcare with shared health records.
- That CSNSW and Justice Health liaise and create mutual policy and procedure (to the extent not otherwise contained in the respective organisations’ policies) so that when a Mandatory Notification is raised and an ISP is created, a notification is provided by CSNSW to Justice Health. Further, Justice Health is to create a policy whereby, upon receipt of that notification, a Justice Health nurse will attend upon the inmate. That Justice Health nurse will inform the inmate that Justice Health are aware of their ISP or RIT status, discuss consent to sharing health information (as set out in Recommendation JH 1) and obtain information to create the Health Problem Notification Form (HPNF), as well as ascertaining and administering to the inmate’s health needs.
To Justice Health:
- A) Further to Joint Recommendation CS/JH 3, that Justice Health introduce policy and procedure to include that when a Justice Health nurse conducts an initial attendance upon an inmate they have been notified is on a Mandatory Notification, ISP or RIT that the Justice Health nurse:
i. Inform the inmate that they can now, or at any stage whilst on the ISP or RIT, provide written consent for Justice Health staff to communicate with specified third party(ies) for the duration of or any specified part of the ISP or RIT, with that consent to indicate the parameters, if any, of information to be provided.
ii. Inform the inmate that such consent will be documented appropriately in their Justice Health file and retained in the event that it is useful or necessary for the management and support of the inmate on the ISP or the RIT.
iii. Inform the inmate that they may withdraw their consent in writing at any time and, that where there is a withdrawal of consent, that will be documented on their file and retained with the inmate’s ISP or RIT documentation.
iv. Provide an opportunity for the inmate to provide such consent for the duration of, or a specified part of, the ISP or RIT.
v. Request the inmate to sign an acknowledgement that the above has been explained to them and that they understand the process. In the event that an inmate does not wish to sign, the Justice Health staff member should record this fact and any reasons expressed by the inmate as to why they do not wish to sign.
vi. Complete the appropriate documentation (with respect to the above) and retain the consent documents.
B) At the time that Justice Health attends a patient placed on an ISP or RIT, the nurse is to provide to the patient with the phone number for the Mental Health Helpline. - That Justice Health staff who are likely to communicate with the family or approved support person for an inmate, including clinical and administrative staff, are provided with guidance and any necessary training on effective communication, the boundaries of confidentiality and the avenues for obtaining consent when necessary; such training should include the use of scripts, consent forms, practical role plays and scenarios.
- A) That Justice Health give consideration to developing a protocol to ensure that when a Justice Health staff member participates in a RIT review meeting that member is, if available, a mental health nurse and if not, that the participating member has access and opportunity to consult with mental health staff either at the centre or via Remote Off-site After-Hours Medical Services (ROAMS).
B) That Justice Health give consideration to implementing a priority referral system for any mental health referrals contained in a CSNSW RIT Management Plan. - That Justice Health give consideration to seeking a joint legal authoritative legal advice addressing the limits and risks of a revokable but enduring consent, in the context of improving the sharing of patient information in custodial health.
To Central Coast LHD and Justice Health :
- That a copy of the “Who is JHFMHN” poster developed by Justice Health be circulated to all New South Wales Health Emergency Departments, and for that document to be brought to the attention of hospital staff to ensure they are aware of relevant contact information to assist where necessary with clinical handover.
