Inquest into the death of DP

Case Number: 2021/94740

Findings Date: 16 November 2023

Magistrate: Harriet Grahame

CORONIAL LAW | death in custody; self-inflicted death; hanging in correctional centre; requests for medical treatment; sleep apnoea; obtaining CPAP machines in custody; adequacy of morning checks

Responses

Recommendations

St Vincent's Correctional Health

St Vincent's Correctional Health formalise a policy acquiring CPAP machines for inmates who require them in custody, including the source and funding of those machines.

St Vincent's Correctional Health consider enhancing the system of patient self-referral at Parklea Correctional Centre, to include access to appointments via telephone.

The Commissioner of Corrective Services NSW

The Commissioner Corrective Services NSW should continue to seek additional funding for the program of cell refurbishment, to progress the removal of obvious ligature points from cells in correctional centres as a matter of urgency.