Inquest into the death of KT

Case Number: 2019/146621

Findings Date: 23 March 2023

Magistrate: Elizabeth Ryan

CORONIAL LAW | death of a person in custody; overdose of clozapine medication; was mental health care of an appropriate standard; recommendations

Responses

Recommendations

The Commissioner of Corrective Services NSW

1) That consideration be given to a procedure whereby, if an inmate is classified for normal cell placement and has recently experienced a traumatic event in their life, including the death of a family member, Corrective Services NSW consider the appropriateness of their cell placement, and take steps to:

a) ask the inmate whether they have a preference to be placed with a cellmate (noting that a range of other factors will also influence the ultimate decision as to cellmate placement), and

b) where the inmate is alone, consider whether it is necessary to make observations or otherwise check in on the inmate at reasonably appropriate intervals.

2) That consideration be given to a procedure whereby the Serious Incident Report author reporting on a death in custody contact the police officer in charge of the investigation, to request updating information as to cause of death, prior to signing off on the Serious Incident Report.

The CEO Justice Health and Custodial Mental Health Network

1) That consideration be given to providing a copy of the Court’s findings in this inquest to the team working on the Pathology Review Project, with a view to informing that Project’s consideration of how to regularise the ordering and signing off of clozapine serum level tests.