Inquest into the death of Benjamin Cullen

Case Number: 2023/55427

Date of Findings: 8 December 2025

Magistrate: Deputy State Coroner, Magistrate David O'Neil

Catchwords: CORONIAL LAW – death in custody - Parklea Correctional Centre - provision of medication - health care in custody - obligations at time of release from custody - provision of medication upon release from custody 

Responses

Recommendations

To St Vincents Correctional Health:

1. That St Vincent's Correctional Health, in consultation with Management & Training Corporation (MTC), the Justice Health, and Forensic Mental Health Network and Corrective Services New South Wales, explore options for real time documentation of medication, administration, and or supply in the electronic medication administration record;

To Management & Training Corporation (MTC) Boardspectrum:

2. That MTC Broadspectrum, in consultation with St Vincent's Correctional Health, review its processes at discharge, including the terms of the discharge checklist completed with inmates shortly prior to their release from custody to ensure its discharge processes are compliant with Corrective Services New South Wales's (CSNSW) policies and procedures, including but not limited to CSNSW's Custodial Operations Policy and Procedure (COPP) Section 23.2