Inquest into the death of SF

Case Number: 2022/00218649

Date of Findings: 8 July 2025

Magistrate: Deputy State Coroner Joan Baptie

CORONIAL LAW – death in custody – self-inflicted injury – adequacy of CSNSW’s (Corrective Services NSW) monitoring – availability of hanging points – assessment and determination of application to go on SMAP (Special Management Area Placement)

Responses

Recommendations 

To the Commissioner of Corrective Services NSW

1. That CSNSW provide training to frontline correctional officers in respect of the management of an inmate’s request for protection or alternative cell placement, including in respect of: 
   • the applicable policies; 
   • the persons authorised to administer the Assessment Tool – Inmates under Threat; and 
   • the requirement or expectation that the Assessment Tool – Inmates under Threat be administered as soon as reasonably practicable or, in the event of policy amendment, within the stated period for completion.
2. That CSNSW reviews its policies and consider imposition of a requirement that where it is determined that an inmate: 
   • may be at risk from others; or 
   • requires alternative cell placement as a result of a threat to the personal safety of the inmate; or, 
   • requires alternative cell placement as a result of a request by the inmate due to fears for their personal safety;

completion of the Assessment Tool – Inmate under Threat, occur within four hours unless in exceptional circumstances.