Inquest into the death of Gavin Ellis

Case Number: 2017/99958

Date of Findings: 2 September 2022

Magistrate: Deputy State Coroner, Magistrate Carmel Forbes

Catchwords: CORONIAL LAW-self-inflicted death in custody- mandatory inquest-adequacy of mental health care-Care Pathways Model for Custodial Mental Health; Renewed Model of Care an Implementation Plan-Waitlists for psychiatric review-Risk Intervention Team- Management in safe cells-Recording of knock up calls- Cell checks at night- ligature points

Responses

Recommendations

To the Commissioner of Corrective Services New South Wales:

1. I recommend allocating funding as a priority, to the removal of ligature points in all Darcy Unit cells at the Metropolitan Remand and Reception Centre (MRRC); and 
2. I recommend consideration be given to adding a requirement for additional random patrols of the Darcy cells in the roles and responsibilities of officers on the B watch at MRRC. 

To the Commissioner of Corrective Services NSW and the Chief Executive Officer, Justice Health and Forensic Mental Health Network:

1. I recommend that consideration be given to what steps could be made to deliver better support and care to inmates who are placed in safe cells, and to inmates who have recently been released from safe cells, including the provision of multidisciplinary services such as occupational therapists, social workers, and psychologists, in order to minimise the likelihood of deterioration of their mental health. 

To the Chief Executive Officer, Justice Health and Forensic Mental Health Network: 

1. I recommend that further training and education be given to Justice Health staff in completing the Health Problem Notification Form in relation to inmates who have been subject to a Risk Intervention Team (RIT), for the purpose of assisting Corrective Services NSW offices identify relevant signs that may indicate risk of self-harm.