Inquest into the death of GS

Case Number: 2018/281398

Findings Date: 3 February 2023

Magistrate: Erin Kennedy

CORONIAL LAW | cause and manner of death; death in custody; mental health; Justice Health waitlists; PAS; complying with patient waitlist timeframes; access to medical practitioners in custody

Responses

Recommendations

Corrective Services NSW

a. That Corrective Services NSW (CSNSW) and the Justice Health and Forensic Mental Health Network (Justice Health) give consideration to the implementation of a written policy or procedure whereby inmates who are being processed for transfer to another correctional centre because of safety concerns at the existing correctional centre, and who are in one-out cell placement pending transfer, are to be referred to Justice Health for assessment.

Justice Health and Forensic Mental Health Network

a. That CSNSW and the Justice Health give consideration to the implementation of a written policy or procedure whereby inmates who are being processed for transfer to another correctional centre because of safety concerns at the existing correctional centre, and who are in one-out cell placement pending transfer, are to be referred to Justice Health for assessment.

b. That Justice Health examine the Patient Administration System (PAS) Waiting List Priority Level Protocol and consider clarifying the clinical priority of a mental health patient who has put in multiple requests for review of their psychiatric medication while on the waitlist for such review.

c. That Justice Health consider introducing a written policy requirement that staff record on the PAS waitlist each time that a patient on an existing waitlist makes a further request for review by the corresponding clinician.

d. That Justice Health consider amending the PAS Waiting List Priority Level Protocol to guide nursing staff in triaging patients who have not been seen off a waitlist within the timeframe corresponding with their clinical priority category (as set out in the PAS Waiting List Priority Level Protocol) and who are therefore overdue for assessment.

e. That Justice Health, considers clearly separating the current reporting of overdue patients on the “Overdue PAS report” into discrete individual clinical priority categories to allow proper analysis of the delays experienced particularly by inmates currently delayed on the waitlist, category 3.

St Vincent's Correctional Health

f. That St Vincent’s Correctional Health (SVCH) examine the policy titled “St Vincent’s Correctional Health: Triage and Priority Waitlist” and consider clarifying the clinical priority of a mental health patient who has put in multiple requests for review of their psychiatric medication while on the waitlist for such review.

g. Recommendation seven: That SVCH consider introducing a written policy requirement that staff record on the PAS waitlist each time that a patient on an existing waitlist makes a further request for review by the corresponding clinician.

h. Recommendation eight: That SVCH consider amending the Triage and Priority Waitlist policy to guide nursing staff in triaging patients who have not been seen off a waitlist within the timeframe corresponding with their clinical priority category (as set out in the Triage and Priority Waitlist policy) and who are therefore overdue for assessment.

GEO Group Australia Pty Ltd

i. That the GEO Group Australia Pty Ltd (GEO Group) give consideration to the implementation of a written policy or procedure whereby inmates who are being processed for transfer to another correctional centre because of safety concerns at Junee Correctional Centre, and who are in one-out cell placement pending transfer, are to be referred to health staff for assessment.

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