Inquest into the death of James Joseph Cunneen

Case Number: 2019/00407715

Date of Findings: 23 July 2025

Magistrate: Deputy State Coroner, David O'Neil

CORONIAL LAW — death in custody — inadequate staffing — one general practitioner for 1150 patients in custodial setting — chaotic delivery of health care in November and December 2019 — nurse led model — multiple failings by nurses 

Responses

Recommendations

1. The Inspector of Custodial Services and the Minister for Corrections be furnished with a copy of the transcript of these proceedings and the findings of the Coroner. 
2. In tangent with Justice Health and Forensic Mental Health Network and considering existing between the flags guidelines, St Vincent’s Correctional Health and other service providers operating in the custodial health space, including those for publicly and privately operated correctional centres, consider updating policy material to provide guidance regarding the timeframes required for medical practitioner review for a patient when medication has been prescribed for an acute condition. 
3. The Commissioner of Corrective Services and the Minister for Corrections be furnished with a copy of the transcript of these proceedings and the findings of the Coroner. 
4. The Commissioner of Corrective Services, having regard to input from Justice Health and Forensic Mental Health Network, take steps to ensure that Management and Training Corporation remains compliant with its contractual obligations with respect to the number of correctional and health staff it is contracted to provide. 
5. The Commissioner of Corrective Services, and the State, give immediate consideration to the redevelopment of the Main Clinic at Parklea Correctional Centre, including the observation cells within the clinic, to ensure a clean, hygienic, and safe environment and one which is fit for the purpose of operating a medical clinic and accommodating patients in cells within the clinic.