Inquest into the death of Milo Wild

Case Number: 2019/154687

Date of Findings: 3 November 2021

Magistrate: Deputy State Coroner, Magistrate Elizabeth Ryan

Catchwords: Hospitals and health care (adults)

Responses

Recommendations

To Justice Health and Forensic Mental Health Network:

1. That the Justice Health and Forensic Mental Health Network ("JHeHS") consider introducing a form of alert or reminder to be built into the JHeHS or Patient Administration System ("PAS")  in order to alert the Medical Appointments Unit and clinical staff, where an inmate patient has been referred for specialist review, but has not seen within the time frame contemplated under the relevant clinical priority category within the PAS Waiting List Priority Level Protocol.
   
   
2. That the Justice Health and Forensic Mental Health Network consider amending the 'Health Assessments in male and female adult correctional centre and police cells policy' [Policy 1.225] to provide that a request for release of information ("ROI") must be submitted to an inmate's known external healthcare provider(s) within 72 hours of the completion of the Reception Screening Assessment.

To the Commissioner of Corrective Services:

1. That Corrective Services NSW consider introducing, in the case of correctional officers who perform medical escort duties, mandatory training regarding the content of the Custodial Operations Policy and Procedures 19.6 and the 'Protocol for guarding inmate patients' prior to commencing such duties, with particular focus on:
   
   (a) the use of restraints for inmate patients
   (b) risk assessments in circumstances where there is a change in the inmate patient's condition
   (c) the role of treating medical practitioners in suggesting a review of security arrangements in respect of an inmate patient's Escort Assessment
   (d) conduct of escorting officers.
   
   
2. That Corrective Services NSW consider providing an information sheet to all hospitals to which inmates are admitted as patients, which summarises the circumstances in which an inmate patient's treating medical practitioners may suggest a review of security arrangements in respect of the inmate patient's Escort Assessment.
   
   
3. That CSNSW consider amending the Custodial Operations Policy and Procedures 19. 6 to provide that correctional officers performing medical escort duties must wear a departmental name badge at all times while on duty.