Inquest into the death of Matthew Grieve

Case Number: 2019/324097

Findings Date: 15 August 2023

Magistrate: David O'Neil

CORONIAL LAW | death in custody; hanging, health problem notification forms; custodial mental health pathways

Responses

Recommendations

Corrective Services NSW

1. In its ongoing review into cell placement Corrective Services NSW (CSNSW) consider the implementation of audit processes for Health Problem Notification Forms (HPNFs) and further education of its employees so as to ensure that HPNFs that are being relied upon are appropriately completed and current.

2b. CSNSW, as part of its cell placement review, consider appropriate steps to take in relation to cell placement, when provided with a new cell placement recommendation from Justice Health and Forensic Mental Health Network (in a new HPNF) when an inmate stops taking prescribed medication.

Justice Health and Forensic Mental Health Network

2a. That the Justice Health and Forensic Mental Health Network consider updating its policy/procedure to require review of a patient’s HPNF specifically as it relates to recommendations which may guide CSNSW cell placement decisions, when the patient stops taking prescribed mental health medication for a clinically significant period. 

3. The Justice Health and Forensic Mental Health Network consider the implementation of audit processes for HPNFs so as to ensure that they are appropriately completed and current.