Inquest into the death of Yohan Wepitiya-Gamage

Case Number: 2016/24535 

Date of Findings: 9 December 2021

Magistrate: Deputy State Coroner, Magistrate Derek Lee

Catchwords: CORONIAL LAW – death in custody, self-inflicted death, Metropolitan Special Programs Centre, psychiatric review, Patient Administration System, Darcy Daily Clinic Tracker Sheet, cell architecture, ligature points, cell placement

Responses

Recommendations

To the Chief Executive, Justice Health & Forensic Mental Health Network:

1. I recommend to the Chief Executive, Justice Health & Forensic Mental Health Network, that the Custodial Mental Health Operations Manual be updated to reflect the introduction and use of the Darcy Daily Clinic Tracker Sheet.