Inquest into the death of Phuoc Van Nguyen

Case Number: 2023/171059

Date of Findings: 30 January 2026 

Magistrate: Deputy State Coroner, Magistrate Derek Lee

Catchwords: CORONIAL LAW –  death in custody, cause and manner of death, Parklea Correctional Centres, searching of inmates prior to internal transfer, assessment of inmates for risk of suicide or self-harm, Instruction PKL 025, reduction and elimination of ligature points

Responses

Recommendations

To the Managing Director of Management & Training Corporation Australia:

1. I recommend to the Managing Director, Management & Training Corporation Australia, that Instruction No: PKL 025 “Inmates Moved in the Main Centre from Area 4” be reviewed and amended so that it expressly provides for:
   (a) a timeframe within which an inmate transferring from Area 4 to the Main Centre is to be assessed for risk of suicide and self-harm; and
   (b) what is to occur if a qualified Risk Intervention Team (RIT) coordinator and a RIT qualified Shift Manager are unavailable to assess an inmate transferring from Area 4 to the Main Centre for risk of suicide or self-harm.
2. I recommend to the Managing Director, Management & Training Corporation Australia, that any necessary steps be taken (whether by education, training or communication) to ensure that all correctional staff to which Instruction No: PKL 025 “Inmates Moved in the Main Centre from Area 4” applies are aware of its contents and understand accurately its terms.