Inquest into the death of Kevin Francis Bugmy

Case Number: 2019/120612

Date of Findings: 6 July 2022

Magistrate: Deputy State Coroner, Magistrate Harriet Grahame

Catchwords: CORONIAL LAW – Death in custody; Death of ATSI man; use of inhalants; cardiac death; assessing the suitability of inmates for employment in correctional centres; excessive prisoner transfers between correctional centres; Aboriginal-specific drug and alcohol programs; availability of Aboriginal case managers; partnerships with Aboriginal Community Controlled Health Organisations; access to Medicare for Aboriginal inmates in custody; coordinated management of chronic inhalant use in custody as a health issue

Responses

Recommendations

To Corrective Services NSW:

1.  That Corrective Services NSW (CSNSW) introduce a system or process that allows CSNSW staff who are assessing the suitability of inmates for employment in business units in correctional centres to determine, from a single source of information that is readily accessible and comprehensive in the information it contains, whether there is any health or medical issue that might be an impediment to the inmate being allocated to a particular business unit. The system of ‘Alerts’ in the Offender Integrated Management System (OIMS) was not effective in the case of Kevin’s death to inform the relevant CSNSW staff at Cessnock Correctional Centre that he should not be employed in an area where chemicals and solvents were available due to his history of inhalational drug use. No relevant, current information or warning was contained within ‘Alerts’, notwithstanding such information was contained in other CSNSW records, including within OIMS. As inmates are transferred between correctional centres, the system adopted should incorporate relevant health or medical alerts from across correctional centres pertaining to a particular inmate and apply statewide. 
2. To support implementation of the above recommendation: that CSNSW adopt a policy, procedure or guideline to guide staff whose task is to assess the suitability of inmates for employment in business units incorrectional centres about the system or process they should follow when doing so. 
3. That CSNSW should review its policies, procedures or guidelines applying to intercorrectional centre prisoner movements with an eye to the case of Kevin who was moved over 50 times in 19 years with a view to reducing prisoner movements in the system. CSNSW should consider in this review the impact of prisoner movements on continuity of health and other care and management issues. The rights of long term prisoners should be specifically considered. 
4. That CSNSW should introduce a system or process that allows CSNSW to monitor the number of inter-correctional centre prisoner movements an individual inmate has undergone to avoid an individual inmate enduring an excessive number of transfers. Excessive interfacility transfers may be inhumane and, in the case of Aboriginal inmates, it may exacerbate social and family dislocation, health issues and cultural disconnection. 
5. That CSNSW should conduct and evaluate a pilot or trial of an Aboriginal-specific drug and alcohol program, being a program that includes culturally appropriate content and integrates Aboriginal perspectives in facilitator training and delivery. 
6. That CSNSW should consider options for increasing the availability of Aboriginal case managers to Aboriginal inmates, particularly to those who need additional support to participate in drug and alcohol programs, such as Kevin did. CSNSW should seek to increase the cultural competency and cultural safety of its workforce and support this with ongoing training, supervision and leadership.

To the Justice Health and FOrensic Mental Health Network:

1. That Justice Health and Forensic Mental Health Network (JHFMHN) should continue to explore and promote partnerships with Aboriginal Community Controlled Health Organisations to support the provision of culturally safe primary health care to Aboriginal patients and, in this context, should explore options for developing funding models that enable partnerships of this kind to be developed and sustained in the long term. 
2. That JHFMHN should continue its work advocating for a trial for access to Medicare for Aboriginal inmates. In this context, JHFMHN should consider liaising with its equivalent or counterpart bodies in other States to coordinate and advocate for a trial process involving Medicare being made available by the Commonwealth to Aboriginal inmates. 

To Corrective Services NSW and Justice Health and Forensic Mental Health Network:

1. That CSNSW and JHFMHN consider convening a high level meeting to discuss how to better manage chronic inhalant use in custody, as a health issue. Consideration should be given to developing a coordinated therapeutic approach from both services.