Case Number: 2024/00008248
Date of Findings: 7 August 2025
Magistrate: Deputy State Coroner, Stuart Devine
CORONIAL LAW – Aboriginal death in custody, cause of death, timeliness of emergency response, adequacy of emergency response, health care whilst in custody, communication between Corrective Services and family members during medical emergency
Responses
| Recommendations to |
Response |
|---|
| Corrective Services NSW |
Awaiting |
Recommendations
To the Commissioner of Corrective Services NSW
- That consideration be given to adopting a procedure at Wellington Correctional Centre that would require at least one incoming and one outgoing officer to be present, so far as possible, in the J Block officers' station, during the handover period between A and C watches, in order to facilitate the timely response to knock-up calls requiring an urgent response.
- That action be taken to investigate and, if appropriate, implement measures to improve the quality of the audio from knock-up calls heard in the monitoring room at Wellington Correctional Centre, including if appropriate by restoring the availability of a functioning handset, and take steps to ensure that monitor room staff are aware of the available hardware for answering knock-up calls.
- The Custodial Operations Procedure and Policy (COPP) 13.2 be amended by the inclusion of a policy that addresses the following:
- a) A requirement for the Governor or OIC to delegate a sufficiently senior correctional officer or other staff member to liaise with the ECP in circumstances where the death of an inmate transferred to hospital may be imminent.
- b) The Governor or OIC or delegated officer must provide the inmate's Emergency Contact Person (ECP) with a contact name and telephone number of a medical professional at the hospital or medical facility to enable the ECP to have a point of contact with them for ongoing communication.
- c) The Governor or OIC or delegated officer being an ongoing point of contact for an inmate's ECP including in terms of any planned transfers.
- d) The Govenor or OIC or delegate must otherwise facilitate contact and arrangements between hospital staff and the inmate's family.
