Inquest into the death of Michael Black

Case Number: 2020/00121160

Date of Findings: 22 August 2025

Magistrate: Deputy State Coroner, Harriet Grahame

CORONIAL LAW – death in custody – Parklea Correctional Centre –stab wound to the chest – use of gaol-made weapon – 18 inmates in holding cell – failure to search inmates – monitoring of CCTV screens – high security and extreme high security designations – decision to revoke segregation direction – waitlist for drug and alcohol assessment – access to opioid substitution therapy in custody

Responses

Recommendations

To the Chief Executive of MTC-Broadspectrum Pty Limited (MTC)

1. MTC review its procedures, instruction, and training as regards the conduct of Segregation Review Committee reviews and the formal lifting of segregation directions, having regard to the findings in these proceedings. This includes, but is not limited to, the importance of documenting reviews and the factors that were considered in determining whether or not to lift a segregation direction (including the appropriate record keeping and/or file management for that documentation).
2. MTC review its procedures, instruction, and training as regard when an inmate should be considered for referral to the High Security Inmate Management Committee for consideration of designation pursuant to Corrective Services NSW (CSNSW) Custodial Operations Policy and Procedure 3.5 (e.g., High Security or Extreme High Security), having regard to the findings in these proceedings.
3. MTC review its procedures with a view to expressly stipulating that specific correctional officers or supervisors who are working in the Reception Area in a given shift must expressly monitor the number of inmates placed in holding cells at a given time and to take steps to prevent unsafe numbers in these cells (including providing instruction on what action to take if an officer is concerned about cell numbers), having regard to the findings in these proceedings.
4. MTC urgently review its current limits on the maximum number of inmates that can be safely held in the cells within the Reception Area of Parklea Correctional Centre, having regard to the findings in these proceedings (this extends to potentially seeking advice from a work health and safety expert in this respect).
5. MTC review any training and instruction it provides Immediate Response Team members in responding to a violent encounter within a cell having regard to any lessons that might be drawn from the events on 22 April 2020 and the findings in this matter (separate to that provided externally by the Corrective Services Security Operations Group).

1. CSNSW and MTC review its arrangements concerning the provision of Serious Incident Reports completed by CSNSW into the death of an inmate at an MTC-operated correctional centre to MTC, having regard to the findings made in these proceedings.