Inquest into the death of Daniel Munro Lewis Turnbull

Case Number: 2022/00317333

Date of Findings: 19 February 2025

Magistrate: Erin Kennedy, Deputy State Coroner

CORONIAL LAW – Correctional inmate, failure to observe signs of illness, natural causes, need to deliver treatment, 24 hour surveillance cell, RIT, mental illness, schizophrenia, psychogenic polydipsia, hyponatremia.

Responses

Recommendations 

To the Commissioner of Corrective Services NSW 

1. That correctional officers in correctional settings are informed and education is provided that:
   • excessive water intake, particularly in a short period of time, can be life threatening,
   • intervention should occur before a person shows signs or complains of symptoms, and
   • if the person does develop symptoms and/or signs, it is a medical emergency.

To the Commissioner of Corrective Services NSW and to the Justice Health and Forensic Mental Health Network

2. That CSNSW and Justice Health and Forensic Mental Health Network policies, and the HPNF, be revised to reflect the fact that excessive water ingestion, particularly over a short period, can be life threatening, and any symptoms and/or signs that suggest excessive water ingestion require immediate intervention regardless of whether an inmate identifies it as a concern.

3. That the Commissioner of Corrective Services NSW consider the production of a memorandum outlining what level of supervision/observation service is provided by CSNSW staff of any inmate placed in an observation cell (including a 24-hour surveillance cell) to clearly identify and communicate to Justice Health what types of physical checks will occur, how often these can reasonably be performed, how often the surveillance camera is expected to be on, who is watching that camera and how regularly it will be staffed and viewed, whether officers are aware/instructed about why an inmate has been placed in an observation cell, how this information is passed across shifts to new officers, and what the officers are instructed to look for. That memorandum is to be provided to Justice Health for circulation to clinical staff to enable the development and management of appropriate inmate treatment plans.