Inquest into the death of Phillip Mitchell Boney

Case Number: 2022/264195

Findings Date: 8 August 2024

Magistrate: Elizabeth Ryan

CORONIAL LAW | mandatory inquest; death of a First Nations man in custody; was custodial mental health care adequate; were cultural needs adequately met; was the transfer of health care information effective; have reasonable efforts been made to reduce risks associated with hanging points

Responses

Recommendations to	Response
Acting Commissioner of Corrective Services NSW	Awaiting
Minister for Corrections	Awaiting
Justice Health and Forensic Mental Health Network	Received (PDF, 555.9 KB)

Recommendations

To the Acting Commissioner of Corrective Service NSW:

Recommendation 1

That immediate steps be taken to remove all hanging points from the John Morony Correctional Centre and to expedite as a matter of urgency, the identification and removal of hanging points in correctional centres throughout NSW.

Recommendation 2

That consideration be given to developing a written procedure, whereby those who supervise offenders under the Crimes (High Risk Offenders) Act 2006 should, unless it is not possible to adequately mitigate risk, supervise First Nations offenders:

• in their own community and on country; or

• if that is not possible, in a community and/or country to which they have strong family and/or cultural connections; and

• where a First Nations offender is unable to return to country or their preferred community, maintaining their cultural connection must be incorporated into their ongoing supervision.

Recommendation 3

That the Acting Commissioner consider requiring as part of case plan reviews (which should occur every two months):

• that the Extended Supervision Team assess whether its existing plan to support a First Nations person around their cultural needs remains appropriate; and

• that the reasons for the conclusion reached is documented.

Recommendation 4

That the Acting Commissioner give consideration to the employment and/or engagement of culturally appropriate psychologists as part of the Violent Offenders Treatment Program.

To the Minister for Corrections

Recommendation 5

• That consideration be given to amending the Crimes (High Risk Offenders) Act 2006 to expressly:

   • recognise the importance of First Nations persons being reasonably supported to maintain their connection to family, community, culture and country; and

   • require consideration to be given to a First Nations person’s cultural needs, and the State’s plan to support the person around those needs, in the determination of an application for an Extended Supervision Order.

Recommendation 6

That consideration be given to amending clause 20(1) of the Crimes (Administration of Sentences) Regulation 2014 (NSW) to expressly require that regard be had to a preference expressed by a First Nations inmate for placement with family members who themselves are in custody.

To the CEO, the Justice Health and Forensic Mental Health Network

Recommendation 7

That the findings in this inquest be considered, as part of the project into developing the Health Problem Notification e-form.

Recommendation 8

That the Justice Health Network, in consultation with Corrective Services NSW, review the efficacy of systems concerning electronic alerts around mental health risks that are auto populated into Corrective Services’ electronic system.