Inquest into the death of Charles Yan

Case Number: 2018/328285

Date of Findings: 3 July 2024

Magistrate: Elizabeth Ryan

CORONIAL LAW | death from drug overdose of a person in correctional centre; was supervision of inmates adequate; was emergency response appropriate; question of recommendations

Responses

Recommendations

Commissioner of Corrective Services NSW

1. That the Commissioner of Corrective Services NSW (CSNSW) undertake a review of the information provided to inmates concerning drug toxicity/overdose, including recognising the signs of overdose, first aid management of persons experiencing overdose and seeking assistance for overdose, within the:

• CSNSW's Health Survival Tips Program; and
• inmate intranet portal, accessible through inmate tablet devices

including in consultation with representatives of the inmate community and, where necessary, with the Justice Health and Forensic Mental Health Network, and any relevant external providers.

2. That consideration be given to consulting with an expert in first aid management of persons who are suffering from drug toxicity, for the purpose of determining if any improvements could be made to the information provided to inmates in recommendation 2 above.