Inquest into the death of Simon Cartwright

Case Number: 2021/00268412

Date of Findings: 3 December 2024

Magistrate: Erin Kennedy

CORONIAL LAW – Correctional inmate, failure to observe signs of illness, failure to diagnose, peptic ulcer, natural causes, failure to identify illness, need to deliver treatment, involuntary detained inmate, waitlist for appropriate mental health facility, mental health treatment, 24 hour surveillance cell, RIT, observation cell, mentally ill person, Section 24, Crimes (Administration of Sentences) Act 1999, 86 of the Mental Health and Cognitive Impairment Forensic Provisions Act 2020.

Responses

Recommendations to	Response
Justice Health and Forensic Mental Health	Awaiting
Commissioner of Corrective Services	Awaiting

Recommendations

To Justice Health and Forensic Mental Health

1. That Justice Health consider a review of policies or procedures for monitoring the food and/or fluid intake of an inmate, with a view to ensuring that food and/or fluid monitoring is undertaken if recommended by a doctor.

2. That Justice Health consider investigating options for:

a) employing psychologists to provide therapeutic services to inmates; and

b) creating systematic support for people with personality disorders in custody.

3. That Justice Health give consideration to recommending a medical transfer of psychiatrically ill patients to external hospitals pursuant to s 24 of the Crimes (Administration of Sentences) Act 1999 in circumstances where no beds are available for a transfer pursuant to s 86 of the Mental Health and Cognitive Impairment Forensic Provisions Act 2020.

To the Commissioner of Corrective Services

4. That Corrective Services consider the implementation of a formal policy that addresses: 

a) the responsibilities of corrective services officers to ensure access to water;

b) the circumstances in which water to an inmate’s cell can be turned off; 

c) the procedures to be followed if the water to an inmate’s cell is to be turned off; 

d) the measures that must be taken to ensure than an inmate has sufficient access to water for drinking and hygiene if their water is turned off; and 

e) requirements for maintaining records in relation to the same. 

5. That Corrective Services give consideration to taking steps to ensure adherence with Custodial Operations Policy and Procedures (COPP) 1.4, subsection 3.4, that requires approval of the governor if an inmate’s placement in an Assessment Cell exceeded 48 hours.

6. That Corrective Services give consideration to mandating Mental Health First Aid training for officers who are assigned to supervising inmates in observation cells and/or on RIT management. 

7. That Corrective Services give consideration to the development of a system that ensures all of those officers who are assigned to supervising inmates in observations cells and/or RIT management are made aware at the start of each shift of the reason why each inmate has been placed in those cells.

To both the Commissioner of Corrective Services and Justice Health and Forensic Mental Health

8. That Corrective Services consider the production of a memorandum outlining what level of service is provided by Corrective Services Staff of an inmate placed in an observation cell (including the 24-hour surveillance cell), to clearly identify and communicate what types of physical checks will occur, how often these can reasonably be performed, how often the surveillance camera is expected to be on, who is watching that camera and how regularly it will be staffed and viewed, and what the officers are instructed to look for. That memorandum is to be provided to Justice Health for consideration of circulation to medical staff to allow development and management of treatment plans.