Inquest into the death of Trevor Samuel

Case Number: 2021/60334

Date of Findings: 21 September 2022

Magistrate: Deputy State Coroner, Magistrate Elizabeth Ryan

Catchwords: CORONIAL LAW – mandatory inquest - death of a person in custody – whether cause of death can be ascertained – whether the Justice Health and Forensic Mental Health Network provided adequate care and treatment.

Responses

Recommendations

To the Minister for Health NSW:

1. That the Minister of Health NSW have regard to these findings, and the statement of Associate Professor Ellis (attached), in considering allocation of funding to ensure that prisoners who require a secure mental health bed are treated in a forensic hospital, rather than in prison cells.

To the Commissioner of Corrective Services NSW:

1. That the Commissioner consider implementing appropriate and continuing mental health training for correctional officers working in Long Bay Hospital.