Inquest into the death of Kerry-Ellen (Nikki) Knight

Case Number: 2021/64779

Date of Findings: 28 September 2022

Magistrate: Deputy State Coroner, Magistrate Harriet Grahame

Catchwords: CORONIAL LAW – Death in custody; presence of hanging points in cells; COVID-19 quarantine; access to telephones; mental health and peer support programs; Reception Screening Assessment (RSA): knock ups; Patient Self Referral Form (PSRF); selfinflicted death

Responses

Recommendations

To Corrective Services NSW:

1. That immediate consideration is given to piloting and supporting a Peer Support Program (such as the Listeners Program) aimed at improving mental health support in custody. Further I recommend that the pilot commence at a womens’ prison as soon as possible and progresses only with full consultation with Justice Health and Forensic Mental Health Network (JHFMHN) in the planning, development and operation of the program.
2. That Cell 5 and other like cells in F Wing of Silverwater Women’s Correctional Centre be refitted to remove hanging points or decommissioned as soon as practicable. 
3. That further consideration is given to initiatives that would alleviate boredom and isolation for inmates kept in COVID-19 quarantine, including but not limited to allowing immediate access to telephone services (irrespective of financial issues), increased time out of cells and recreational activities. 
4. That Correctives Services NSW (CSNSW) review its processes to ensure that a record is made when there is a knock up call that requires attendance at a cell by CSNSW, and/or a request to be made for the attendance by JHFMHN.

To Justice Health and Forensic Mental Health Network:

1. That consideration is given to making it a requirement to scan and upload any patient selfreferral form (PSRF) into the patient’s electronic medical record. 
2. That consideration is given to amending Justice Health Policy 1.225 “Health Assessments in Male and Female Adult Correctional Centres and Police Cells” to include at 3.2.1 a requirement for the nurse conducting the RSA to undertake a review of the medical records. The following wording could be considered:
   Where possible, the RN or EN should undertake a review of any recent medical records held by Justice Health in relation to the patient, particularly in circumstances where the patient is not responding or communicative or where information received during the assessment is inconsistent with any active or inactive PAS alerts or health conditions. 
3. That JHFMHN review its processes for recording verbal requests received from CSNSW for attendance on an inmate in relation to a medical issue.