APPEND/Xi Victorian Correctional Services Task Force ... · APPEND/Xi Victorian Correctional Services Task Force ... Prisoner Profile Summary ... British Psychological Society

Introduction

APPEND/Xi

Victorian Correctional Services Task Force

Review of Suicides and Self Harm

The issue of self harm and suicide in prisons is an issue requiring continuing attention by

prison managements. Incidents in the Victorian prison system in the past year indicate

that it is timely to review prisoner reception and risk assessment processes, and

specifically to focus on suicide and self harm management regimes and their

implementation in the Port Phillip and Beech worth Prisons.

The reception and assessment and orientation of prisoners is a critical function in the

management of prisoners within a corrections system. The central focus of this process is

the identification of prisoners who may be at risk so that appropriate decisions on their

classification, placement and management can be made. Classification and placement of

prisoners is the responsibility of the Office of the Correctional Services Commissioner.

Most prisoners are inducted into the Victorian prison system via the Melbourne

Assessment Prison (MAP). Once classified they are then dispersed to specific prisons

commensurate with their security rating and classification requirements.

Over the past 12 months there have been six deaths in Port Phillip Prison and three deaths

in Beechworth Prison, apparently from unnatural causes. Coronia! inquiries into these

deaths are scheduled for 1999.

Port Phillip Prison

Port Phillip Prison is a private prison which commenced operation in early September

1997 as a 600-bed male prison. In the ensuing four months there was a staged build-up of

prisoners at the prison to facilitate an orderly commissioning process. The operation of

Port Phillip Prison is the subject of a Prison Services Agreement between the Minister for

Corrections and Australian Correctional Facilities Pty Ltd, the private consortium which

owns the facility at Laverton. The operator of the prison is Group 4 Corrections Services

Pty Ltd on behalf of Australian Correctional Facilities Pty Ltd.

The Prison Services Agreement for Port Phillip Prison was signed on 10 July 1996,

following a bidding process based on a brief to short-listed parties issued in August 1995.

The brief to short-listed parties was titled "Development, Ownership and Operation of the

Men's Metropolitan Prison". This brief and the Prison Services Agreement encompass the

objectives, prison management framework and service standards for the prison.

A document titled "Prison Operating Manual" documents the management regime

developed by the Prison Operator to operationalise the prison. The Prison Operating

Manual is endorsed by the Commissioner Correctional Services and is specifically

provided for in the Prison Services Agreement. The Prison Operating Manual includes a

regime for the prevention and management of incidents of suicides and self harm.

Prisoner Profile Summary

Security Average No. Peak No. Rating

Remand - Mainstream A!B 240 Up to 340

Remand - Protection A!B *45 60

Sentenced- Mainstream A!B/C 155 ·- 210

Sentenced- Protection A!B/C **40 60

Security Capacity Expected

Rating Occupancy

Levels Management/Security Unit AIBIC 35 30

Special Care Unit AIBIC 35 35

Health Care - Prison Hospital AIBIC 20 17

Psycho-social Unit 30 30

600

* Includes ten high protection prisoners

** Includes ten protection sentenced prisoners

Beechworth Prison

Beechworth Prison is a 123 bed medium security prison operated by CORE - the Public

Correctional Enterprise. CORE is a service agency within the Department of Justice.

Pursuant to the Service Agreement, CORE operates ten prisons, accommodating a range of

prisoner profiles, and manages community correctional services.

Beechworth Prison accommodates prisoners who are vulnerable and/or have had

difficulties coping with mainstream prison life. A number of prisoners are able to transfer

to mainstream prisons after a period of preparation at Beech worth prison.

CORE has developed Prison Operating Manuals that document the management regime

implemented to operationalise each of its ten prisons. The Operating Manuals provide for

a common set of procedures to be followed at all prisons for general prison functioning

and a specific set of procedures appropriate to the prisoner population of each of the

prisons.

Review

The incidence of suicides in Victorian prisons, especially Port Phillip and Beechworth

Prisons, is the cause of growing concern for correctional authorities.

Therefore, in view of the incidents that have occurred over the past year, it is timely to

conduct a review of existing policies and procedures for the identification of at risk

prisoners, and to specifically evaluate the adequacy and implementation effectiveness of

the suicide and self harm management regimes at the two prisons. The aims of the review

are to validate current processes, to identify improvement strategies and to recommend any

changes that will assist in reducing the level of suicide and self harm in Victoria's prisons.

A review will be conducted, pursuant to the Corrections Act 1986 (Clauses 1 and SE) and

Clause 27 of the Prison Services Agreement for the Men's Metropolitan Prison (executed

in July 1996) and Clause 11 of ANNEXURE T to the Agreement.

A Steering Committee will provide guidance to the panel. The Steering Committee will

comprise the Secretary, Deputy Secretary (Justice Operations) and Acting Commissioner,

Correctional Services.

Terms of Reference

The Terms of Reference of the Task Force will be:

l. To examine the adequacy and effectiveness of existing policies, practices and

procedures for the reception, assessment and orientation of prisoners into the Victorian

prison system.

2. To examine incidents of unnatural deaths and serious incidents of self harm from

August 1997 at Port Phillip and Beechworth Prisons.1

3. To identify action that can be taken by the management of the respective prisons to

enhance practices and improve the management of at risk and vulnerable prisoners.

4. To identify action that can be taken by the Department by way of changes to policies

and standards and reporting requirements.

5. To make appropriate recommendations for consideration by the Department and service

providers.

1 It should be noted that the recent incidents of unnatural deaths at the Metropolitan Women's Correctional Centre and the Melbourne Assessment Prison have been incorporated into- point 2 of the Terms of Reference.

Panel:

Peter Kirby

Sue Wynne-Hughes

Professor Paul Mullen

Secretariat:

Alby Bentincontri

Michael Carroll

Viktor Urjadko

APPENDIX2

Task Force Membership

-Chair

- Executive Officer

- Project Consultant

- Project Consultant

The Secretariat was assisted by Jennifer Peck, Agnes Waclawik and Brooke White.

Name

Don Keens

Dr Chris Cantor

Amanda George

Liz Curran

Paul Delphine

Andrew Stripp

Judy Cox

Catherine Gow

Pauline Spencer

Terry Easthope

Tony Wood

Terry O'Donoghue

David Green

APPENDIXJ

Submissions Received by the Task Force

Position

Managing Director

Senior Research Psychiatrist

Solicitor

Executive Officer

Acting ChiefExecutive Officer

Assistant Director, Mental Health

Corrections Working Group



General Manager

Director of Business Development

Acting Commissioner

Public Advocate

Organisation

Australasian Correctional Management Pty Ltd

Australian Institute for Suicide Research and Prevention, Griffith University

Brimbank Legal Centre

Catholic Commission for Justice, Development and Peace

CORE- the Public Correctional Enterprise

Department of Human Services

Federation of Community Legal Centres


Federation of CommunityLegal Centres

Fulham Correctional Centre

Group 4 Correction Services Pty Ltd

Office of the Correctional Services Commissioner

Office of the Public Advocate

Dr Barrie Kenny

David McDonnell

Peter Norden, S.J.

Anthony Calabro

Rev Judy Redman

Rev Lesley-Anne Curran

Ken Gregson

Antoinette Gentile

Dr Douglas Bell

Michael Burt

Dame Phyllis Frost

Consultant Psychiatrist

Director

Director

Executive Director

Outreach Ministries Co-ordinator

Senior Prison Chaplain

Acting Executive Officer

Acting Deputy Chief Executive Officer

Consultant Psychiatrist

Chief Executive Officer

Patron

Port Phillip Prison

Port Phillip Prison

The Ignatius Centre for Social Policy and Research

The Victorian Offender Support Agency (VOSA)

Uniting Church in Australia, Synod of Victoria

Uniting Church of Australia, Synod of Victoria

Victorian Association for the Care and Resettlement of Offenders (V ACRO)

Victorian Aboriginal Legal Service Co-operative

Victorian Institute of Forensic Mental Health

Victorian Institute of Forensic Mental Health

Windermere Child and Family Services

Name

Amanda George

Charandev Singh

Anne Riley

JeffThomas

John Griffin

Paul Delphine

Andrew Stripp

Gavin Jackson

Joanna Birdseye

Catherine Gow

Pauline Spencer

Rebecca Phelan

Helen Camaby

Karen Taylor

Dorothy Cherrie

APPENDIX4

People Interviewed by the Task Force

Position

Solicitor

Representative

Acting Manager, Offender Services

Acting General Manager, Northern Region

Chief Executive 0 fficer

Acting Chief Executive Office

Assistant Director, Mental Health

Manager, Policy, Standards and Monitoring

Manager, Service Monitoring and Review




Support and Resource Officer

Support and Resource Officer

Representative

Organisation

Brimbank Legal Centre

Coburg Legal Centre


CORE - the Public Correctional Enterprise


CORE -the Public Correctional Enterprise







Flat Out Inc

Flat Out Inc

Flat Out Inc

Julie Lowe Representative Flat Out Inc

Terry Easthope General Manager Fulham Correctional Centre

Tony Wood Director of Business Group 4 Correction Services Development Pty Ltd

David Banks Managing Director, Prison and Group 4 Securitas NV Court Services

Tony Jenkins Program Manager HM Prison Beechworth

Rod Kelso Operations Manager HM Prison Beechworth

Eric Edward Official Visitor HM Prison Beechworth

Jack Jacoby Managing Director Jacoby Consulting Group Pty Ltd

Bob Herron Deputy General Manager Melbourne Assessment Prison

Tony Phillips General Manager Melbourne Assessment Prison

Rod Wise Health Services Manager Melbourne Assessment Prison

Kelvin Anderson General Manager Metropolitan Women's Correctional Centre

Isabel Hight Director, Sentence Management Office of the Correctional Services Commissioner

Terry O'Donoghue f>.cting Commissioner Office of the Correctional Services Commissioner

David Green The Public Advocate Office of the Public Advocate

Fred Wright Advocate Office of the Public Advocate

Maureen Hanley Health Services Manager Pacific Shores Health Services

David McDonnell Director Port Phillip Prison

Shane Kelly Acting Director Port Phillip Prison

Klaus Walden-Baur Programs Manager Port Phillip Prison

Felicity Dunne Consultant Clinical Port Phillip Prison Psychologist

Dr Eugenie Tuck Clinical Director, Correctional St Vincent's Hospital, Port Health Phillip Prison

Robina Bradley Business Manager, Correctional St Vincent's Hospital, Port Health Phillip Prison

Graeme Johnston State Coroner, Victoria State Coroner's Office, Victoria

Michael Burt Chief Executive Officer Victorian Institute of Forensic Mental Health

Dr Douglas Bell Consultant Psychiatrist Victorian Institute of Forensic Mental Health

APPENDIX5

Prisons Visited by the Task Force

HM Prison, Beechworth

Melbourne Assessment Prison, Spencer Street, Melbourne

Metropolitan Women's Correctional Centre, Deer Park

Port Phillip Prison, Laverton

APPENDIX6

References

ACT Corrective Services, Department of Justice and Community Safety (1998). National Workshop One Strategies for the Reduction of Self Harm in Custody, 29 July 1998. Notes from transcripts of the meeting

Australian Institute of Criminology (March 1998). Trends and Issues No. 80: Australian Deaths in Custody & Custody-related Police Operations, 1997

Biles, D. (June 1990). International Review of Deaths in Custody, Research Paper No.15 prepared for the Royal Commission into Aboriginal Deaths in Custody

Bogue, J. & Power, K. (December 1995). "Suicide in Scottish Prisons, 1976-93", The Journal of Forensic Psychiatry, Vo1.6 No.3

Bureau of Justice Statistics (1996). Sourcebook of Criminal Justice Statistics (US)

CORE -the Public Correctional Enterprise {February 1996). Suicide and Self-Harm in Victorian Prisons: 1990-1994

CORE -the Public Correctional Enterprise {September 1998). HM Re-integration Prison Beech worth. Offender Management Services - Policy and Procedural Review

Correctional Services Division, Victorian Prison Service, Department of Justice, Victoria (November 1994). Review of Victorian Prisons Drug Strategy

Corrections Operations Group, Department of Justice, New Zealand (1995). Review of Suicide Prevention in Prisons, Report of the Suicide Prevention Review Group, New Zealand

Cox, Marshauser (1998). Solution to the Problem of Jail Suicide

Crighton, D.A. & Tow!, G.J. (1997). Self-inflicted deaths in prison in England and Wales: an analysis of the data for 1988-90 and 1994-95. In G.J. Towl (Ed.) Suicide and Self-Injury in Prisons. Division of Criminological and Legal Psychology 28. Leicester, UK: British Psychological Society

Crisis, The Journal of Crisis Intervention and Suicide -Prevention - Volume 18, Number 4 (1997). A Special Issue Prison Suicide

Dear, G., Thompson, D., Hall, G. & Howells, K. (1997). Self harm in Western Australian Prisons: An examination of situational and psychological factors. School of Psychology, Edith Cowan University, W A

Denoon (1993) quoted in Hayes, In Correction Medicine, ed. M Puisis, Mosby, St Louis, USA (1998)

Department for Correctional Services (1998). Policy 5 Australia

Throughcare. South

Department of Justice, Victoria (June 1997). New Prisons Project. Brief to ShortListed Parties to Submit a Firm Offer for the Development, Ownership & Operation of the Men's Metropolitan Prison. (Brief originally issued August 1995)

Dickens, C. ( 1842). American Notes

Eyland, Carber, Barton (1998). Suicide Prevention in 1\fSW Correctional Centres

Farmer, K.A. (1996). Medically serious suicide attempts in a jail with a suicide prevention program. Journal of Forensic Sciences, Vol. 4 No.2:240-246

Fisher, W.A. (1994 ). Restraint and seclusion: a review of the literature. American Journal of Psychiatry, Vol. 151:1584-1591

Galloway, J. (1997). Forsaken on Romeo Block. Article from The Guardian Weekend, 8 February 1997 (UK)

Grassian, S. (1983). Psychopathological effects of solitary confinement. American Journal of Psychiatry, 140:1450-1454

Gunn, J. (1996). Suicide Prevention in Scottish Prisons

Hansard (1998). Prisoners Suicides Written Answers 12 Feb & 7 May and Select Committee on Home Affairs Minutes of Evidence Annex D. House of Commons (Internet)

Harding, R. W. ( 1990). Review of Suicide and Suicide Attempts by Prisoners in the Custody of the Office of Corrections, Victoria (unpublished)

Harding, R.W. (1997). Private Prison & Public Accountability. Open University Press

Inquest ( 1997). Annual Report 1997 (UK)

Johnston, Commissioner Elliott QC (1991). National Report, Volume 1. Report of the Royal Commission into Aboriginal Deaths in Custody, Australia

Johnston, Commissioner Elliott QC (1991). National Report, Volume 5. Report of the Royal Commission into Aboriginal Deaths in Custody, Australia

Laisher, J. (1997). Inmate Suicides in Correctional Service of Canada

Liebling, A. (1992). Suicides in Prison. Routledge Chapman & Hall Inc.

Offender Management Division, Ministry of Justice (August 1998). Report of the Strategic Group on Suicide Prevention Strategies for Prisons in Western Australia, WA

Office of the Correctional Services Commissioner, Department of Justice, Victoria (1998). Sentence Management Policy Manual (Draft)

Office of the Correctional Services Commissioner, Department of Justice, Victoria (September 1996). Men's Prisons in Victoria- Correctional Policy and Management Standards

Office of the Correctional Services Commissioner, Department of Justice, Victoria (April 1998). Adult Corrections in Victoria. (Draft)

Power, Dr K.G. (January 1997). Evaluation of the Scottish Prison Service Suicide Prevention Strategy. Scottish Prison Service Occasional Papers, Report No.l/1997

PriceWaterhouseCoopers (1998). Review of Self-Harm and Suicide Management Procedures Port Phillip Prison.

Prison Reform Trust. (April 1997). The Rising Toll of Prison Suicide

Prison Service News. (May 1998). Stopping Suicide

Queensland Corrective Services Commission (June 1997). Sentence lvfanagement Procedures (Sections L to 1.6.3)

Queensland Corrective Services Commission (September 1997). Chapter 22: Policy and Procedures Manual Custodial Corrections Crisis Support Unit and Chapter 18: Case Management

Queensland Corrective Services Commission. (1996/97). Annual Report. (Section on Aboriginal and Torres Strait Islander Support Unit)

Queensland Corrective Services Commission. (14.5.94) Commission's Rule 135 -Attempted Suicide

Queensland Corrective Services Commission. (14.12. 94) Commission's Rule 155 -Buddy System Suicide Prevention

Queensland Corrective Services Commission. (17.10.96) Commission's Rule 185-Deaths in Custody

Queensland Corrective Services Commission. (1.6.98) Commission's Rule 214 -Suicide Prevention

Reser, J.P. (October 1989). The Design of Safe and Humane Police Cells. A Discussion of Some Issues Relating to Aboriginal People in Police Custody. Research Paper No.9 prepared for the Royal Commission into Aboriginal Deaths in Custody

Rowan J.R. & Ha yes L.M. ( 1988). prevention in joints and lock-ups. Institutions and Alternatives

Training curriculum on suicide detection and Alexandria, Virginia: National Center on

Royal Commission into Aboriginal Deaths in Custody - Interim Report ( 1988) (knovvn as the "Muirhead Report"). Muirhead J.

Scottish Prison Service. ( 1998). Act and Care, Suicide Risk Management Strategy

Solicitor General Canada (1997). Basic Facts About Corrections in Canada

Suedfeld, P. (1974). Sensory Isolation: A case for inter-disciplinary research. Canadian Psychologist 15(1):1-15

Syme, D. & Watson-Munro, T. (1985). Prison Suicide and k!ethods of Prevention. Report to the Hon. J. Kennan

Victorian Government (1997). Response to Suicide Prevention Taskforce Report

Victorian Task Force Report (July 1997). Suicide Prevention Executive Summary

Victorian Task Force Report (July 1997). Suicide Prevention

Wailer, K. (1993 ). Report on Suicide and Self-Harm in Correctional Centres (unpublished)

APPENDIX7

List of Reports into Unnatural Deaths Reviewed by the Task Force

Name of Prisoner Documents

Michael John ALDER TON • "Report into the Death of Prisoner Michael John Alderton (CRll/ 1779) at the Melbourne Custody Centre 22 November 1995" prepared by Correctional Services Division, Department of Justice, July 1996

Cheryl BLACK

Robert Michael BRADFORD

Robert Paul DERRICK

• Memo 19 December 1997 from Paul Delphine, Director, Prison Services CORE to John Van Groningen, Commissioner, Office of the Correctional Services Commissioner "Coronia! Inquest - Michael John Alderton CRN 1779"

• Memo 14 January 1998 from John Van Groningen, Commissioner, Office of the Correctional Services Commissioner to Minister for Corrections "Media Reports: Alderton Inquest"

• "Report into the Death of Prisoner Cheryl Faye Black (CRN 77822) at the Metropolitan Women's Correctional Centre on 30 March 1997"- prepared by Monitoring and Assessment Branch, Office of the Correctional Services Commissioner, January 1998

• "Report of Inspectors into the Death in Custody of Robert Michael Bradford at Arthur Gorrie Correctional Centre on 29 July 1998" .. prepared by Mr John Illijevic and Dr Monika Henderson for Queensland Corrective Services Commission

• "Final Report into the Death in Custody of Robert Paul Derrick at Townsville Correctional Centre on 15 November 1997" prepared by Inspectors Wayne Saunders, Norm Wilson and Fred Richardson for the Queensland Corrective Services Commission

Name of Prisoner Documents

George Andrew DRINKEN • "Report into the Death of Prisoner George Drinken CRN 58335 at Port Phil!ip Prison on 30th October 1997- Volume One Report and Volume Two Appendices" - compiled by J B Barclay (IA001427), Cobra Executive Protection on behalf of Group 4 Corrections Services Pty Ltd

• Letter from J B Barclay (IAOO 1427), Cobra Executive Protection to Mr David McDonnell, Director, Port Phillip Prison, Laverton "Death in Custody ofGeorge Andrew Drinken, CRN 58335 at Port Phillip Prison on 30110197 Additional Information" "

Michael FILIPS • "Report into the Death of Prisoner Michael Filips CRN 132097 at St Vincent's Hospital on the 19th of March 1998" - compiled by J B Barclay (IA001427), Cobra Executive Protection on behalf of Group 4 Corrections Services Pty Ltd

Neil David HUMPHRIES • "Report into the Death of Prisoner Neil David Humphries (CRN 95441) at the Melbourne Assessment Prison on 16 May 1998" prepared by the Continuous Improvement Unit, CORE the Public Correctional Enterprise, July 1998

Adam Courtney IRWIN • "Report into the Death of Prisoner Adam Courtney Jrwin CRN 130384 at Port Phi/lip Prison on the 16th of December 1997: Appendices" - compiled by J B Barclay (IA001427), Cobra Executive Protection on behalf of Group 4 Corrections Services Pty Ltd

Paul John KEATING • "Report into the death of prisoner Paul John Keating (CRN 42935) at HM Prison Beechworth on 10 August 1997" - prepared by Manager, Operational Review, CORE the Public Correctional Enterprise, Department of Justice, December 1997

Rodney David KOERS • "Report into the Death of Prisoner Rodney David Koers CRN 49743 at Port Phi/lip Prison on the 19th of March 1998 Report and Appendices" -compiled by J B Barclay (IAOOI427), Cobra Executive Protection on behalf of Group 4 Corrections Services Pty Ltd

Name of Prisoner

Colin John LAFFEY

Vienh Chi TU

Documents

• "Report into the Death of Prisoner Colin John Laffey (CRN 63473) at HM Prison Beechworth on 24 October 1997" prepared by Operational Review Unit, CORE - the Public Correctional Enterprise, February 1998

• "Report into the Death of Prisoner Vienh Chi Tu (CRN 108722) at Port Phillip Prison on 4/1198: Volume Two Appendices" -· compiled by J B Barclay (IA001427), Cobra Executive Protection on behalf of Group 4 Corrections Services Pty Ltd

APPENDJX8

Coronial and Death Inquiry Recommendations January 1990-0ctober 1998

I.

Name

ALDER TON Michael John

Date: 22/ll/!995 Location : Melbourne

Custody Centre

Metlwtl

llanging

Commeuls!Recommeutlatious

Coroner

The Victoria Police and the Office of the Correctional Services Commissioner consider an integrated information system eventually utilising computer technology to assist in the management of at risk prisoners.

I. That Victoria Police and the Office of the Correctional Services Commission consider developing an information 2 standard aimed at improving the accuracy of data entered on the system for the management of at risk prisoners.

l. A performance audit be introduced and regularly undertaken on Police and Corrections files to check that information 3 contained in the files is timely, relevant and useful for the management of prisoners at risk. Where there is a file on a

prisoner held by more than one agency (Police and Corrections· public or private) it is essential that comparative audits be undertaken to ensure a uniformity of information. It is suggested that the audit be conducted jointly by Victoria Police and the Office of the Correctional Services Commissioner.

I. That Victoria Police and the Oftice of the Correctional Services Commissioner consider research into t11c indcknts where 4 failures in information gathering, access or exchange, etc. has been a factor.

I. That Victoria Police and the Oftlce of the Correctional Services Commissioner ensure that systems are in place so that 5 where a prisoner (who is required to take prescribed drugs) is being transported that those drugs are not left behind.

I. That Victoria Police and the Office of the Correctional Services Commissioner consider jointly developing a special 6 training system for Police who may be required to work in areas where prisoner management is part of

responsibility

I. That consideration be given to developing minimum standards for cell design aiming at the elimination of hanging points 7 and providing for humane cell architecture.

I. That the issue of the failure to provide observers for the cell monitors in the reception area on the aftcnl()on of 8 Mr Aldcrton's death be examined. In the event that a system of regular observers is not provided for the monitors this

should be considered as an important part of the management of prisoners at risk.

Coronial and Death Inquiry Recommendations - continued I

Name Method Commeuts/Reco/1111/eudatioi/J

ALDER TON Michael John (Continued) CORE lnqui•y

I. 9 That Statewide Records cease the practice of destroying Form 450 Prisoner Information Records upon notilication that a prisoner has received a custodial sentence and enclose the document in the prisoners Warrant Cover until the date of his/her discharge.

1.10 That should further Goal Orders be issued for the prisoner to appear before a court at a later date the Form 450 is retrieved from the Warrant Cover and forwarded with the prisoner being transferred into police custody.

1.11 That the Form 450 is archived along with the other documentation upon the prisoner's discharge ll1r future reference if necessary.

1.12 That the Form 450 Prisoner Information record is made available to 'F' Assessment staff when conducting their interviews with remanded and recently sentenced prisoners and that any further pertinent information is brought to their attention by either forwarding the document or a copy thereof to them by Records Stall

2

Coronial und Death 'nquiry Recommendations - continued

2. Name

ALEX John Dale: 0710611995 Location: //M Metropolilan 1/eception Prison, Pen/ridge

Metlwtl

llanging

Commeuts/Recommeudatious

Coroner

2.1 ... the need for vigilance and an increasing focus on the training of prison onicers in stlidde awareness.

2.2 Measures designed to improve communication of health or welfare concerns about prisoners between their families/friends and the prison system must be encouraged.

2.3 Correctional Services consider providing visitors with an information sheet encouraging reporting of appropriate health/welfare concerns to prison otlicers or the Commission.

2.4 ... improving communication levels between concerned family/friends and Correctional Services.

2.5 Communication between Human Services Case Workers and Corrections.

2.6 ... a protocol between her Department (Child Protection Workers) and Corrections. This suggestion may h~ worthy of examination

2, 7 Suicide awareness programs for professional prison ofticers would be a vital el~mcnt of any prcwntion program in the correctional system.

2.8 ln this regard it is axiomatic that regular training (and retraining) in the area of suicide awareness is ~ssential.

2.9 Corrections review the circumstances of the recommendation for psychological counselling in this case to id~ntify any potential improvements in delivery ofthe service to prisoners.

2.10 Procedures need to be developed to ensure the risk of this type of failure in an investigation process are minimised.

2.11 Corrections consider reviewing its investigatory practices to ensure that all olliccrs who have rdcvant information 111 a death in custody investigation arc identified and that material is provided either to the internal inquiry or police.

3

Coronial and Death Inquiry Recommendations - continued

Name Metlwd

3. BLACK Cheryl Date. 3()10311997 Natural Location : Metropolitan Causes Women "s Correctional Centre 3.

Comments/Recomttll!l!d(l/ions

Commissioner's ileporl ilecommendatiom

The prison incorporates into its emergency response procedures the need for an ambulance to be called If local medical stafflind there is no need for the ambulance it could be cancelled rather than

have unnecessary delays for an injured or sick prisoner for whom a move to hospital may be

3.2 That prison management revise the prison's current policy manual Section 8-114, to indicate:- I. No authorised persons enter the crime scene at the end of an incident until police have arrived and completed their work, and; 2. No aspect of the crime scene be unnecessarily disturbed.

3.4 That management review officer practices in regard to the recording of information on prisoner files, particularly the prisoner's IMF.

13.5 Prison management ensure reception starf are remintkd of their responsibility l(lr contacting the Department of lluman Services to ensure the management ol" prisoners under the supervision of that Department is mnt inued whilst the individual is in prison.

3.6

3.7

Group 4 c1ppoimed independent investigator Recommendations

Officer training emphasise the need to keep detailed and contemporaneous notes when to incidents, events. The indicate the need for more detail.

_ to assist officers when experienced.

deceased persons - to them cope with the stress

3.8 Orientation program to help officers prepare for giving evidence at court- Coronia! hearings, and criminal hearings

I I

4

Coronia! and Death Inquiry Recommendations - continued

Name

l3LACK Cheryl (Continued)

Method Commeuts/R ecomme 11 tlalimts

Group 4 appoinled independent investigator Recommendations (Continued)

3.9 Install a secure cabinet/safe to safe before handing over to Police, to

contraband seized; and a secure cabinet to hold evidence collected, continuity in evidence chain.

3.10 Any visit to any cell, for whatever reason, needs to be included on officer's

3.11 MWCC management needs to reiterate to staff the procedures relevant to the removal of coverings from the observation panels of cell doors.

5


4.

Name Met/we/

BOITERILL Thomas Edward Date· 1410911994 Ilanging

Location : Melropolilan

Reception Centre, Pentridge

C o m men tsl R eco lllltlen tla tions

Coroner 4.1 It is of concern the minute observations rigidly adhered to.

4.2 ... namely that the current method of recording observations be changed so that each staff member recording such entries be required to note the exact time at which he or she made the observation

4.2 I recommend that a system be introduced to ensure that all informmion obtained by investigating police regarding a prisoner's suicide potential which would in accordance with Police Circular Memo 95-2-1 be required to accompany the prisoner during translers between police cells be applied to transfers to any facility operated by the Onice of Corrections and thereatier be handed to ot1icers accompanying u prisoner between Divisions at such a facility.

OR&llnq11iry

4.3 That Prisons Operations Branch reframe the current policy to rellect that the personal distribution of Infection Control Pouches to staff is appropriate provided safeguards are implemented to ensure that pouches are carried at all times, that contents are regularly checked and that staff are aware of the procedures for replenishing the pouch contents.

4.4 That Shift Supervisors at the Metropolitan Reception Prison ensure that watch staff issued with prison two way radios carry these radios at all times during their watch period.

4.5 That Metropolitan Reception Prison, Prison Management • discontinue the practice of providing prison issue calico storage bags to prisoners in the AAU;

introduce appropriate alternative options for prisoners in the AAU to store their property; assess all prisoner property available to prisoners in the AAU against its potential use by prisoners for the purposes of self harm.

4.6 That prison management take immediate action to ensure that obvious anchorage points be removed and that a review of cell !itout and design be undertaken.

6

Coronia) and Death Inquiry Recommendations - continued

Ntmte

5. BUTTERL Y Arc hie

6.

Fcrguson Date · { 3/03/{993

Location · Picnic l'oint, Jamieson

CHADWICK George lames Date: 28/04/1996

Location . !I M Prison Langi Kal Kal

Metlwtl

Gunshot

Ischaemic heart disease

Severe coronary atheroscler os is

5.1

CtJ/1111/ellt.vRecommeutlatiou.\·

Coroner

The Oflicc of Corrections were aware of some aspects of the developing relationship. Clearly it should not have been permitted to reach the stage it did.

5.2 Procedures have been established to address issues associated with the potential for the development of inappropriate relationships within the prison system

5.3 Protocols may need further examination to ensure isolation of suspects from potential contamination sources.

6.1

6.2

6.3

6.4

CORE's lnquiry

That the Medical Orticer he asked to provide an 'on call' roster to both prison.~ ill the ltcgiun tu CIISttrc that otily one phone call needs to he made when emergency nwdical assistance is required.

That Langi Kal Kal Prison Management arrange for CPR refresher training for staff, including the use of the Air-ViV<J and Oxy-Viva systems.

That Langi Kal Kal Prison Management ensure any future major incident debrief is chaired by a senior ofticer who was not directly involved in the incident.

That Langi Kal Kal Prison Management ensure that regular checks are undertaken of the contcnls in Emergency Pouches to confirm that they are lully equipped and in good working order.

7


7.

Name

CREMMEN Paul Kcvin

Date .· 06/051 I 990

Location A Division, liMP Pen/ridge

Method

Stabbing

7.1

7.2

7.3

7.4

7.5

CommeiJis!Recomulelllllltions

Ueport Necommendations

That the Director of Prisons give consideration to the introduction of the clearly marked tape to provide an immediate boundary to any major incident scene in order to prevent unauthorised access and preserve the incident scene and evidence that might be in the vicinity.

That on the death of prisoner John A. Shea I commented on the absence of reports submitted to the Governor, from those oflicers directly involved in the incident. The reported stated: "It is important that all Prison Officers who have any involvement or observations to nHlke in the case of a prisoner death )or any major prison incident) submit a formal report to the governor prior completion of duty on that day"

It is noted that the Victorian Police were the only emergency service agency represented ut the debriding meeting. No invitation was extended to the M.F.l3. and Ambulance Service_

would have been useful to have the benclit of comment from ull of the emergency scrvic.; agencies that pal'licipatt.:<l on the day, irrespective of the amount of direct involvement in the incident{s)-

The debriefing meeting was held I 0 days after the incident. In order to maximise the benefits of the debriefing it is important for this process to occur as soon as possible after the incident. In this regard it would have been preferable for the debrief meeting to have occurred within 2 3 days of the incident.

8


Name

8. CRUPI Vinccnw Antonio Date : 2 I 104/ I 996

Location · Bank.sia Unit, Barwon Prison

9. DANG Huy Due Date: 08109/1991

Location : St Vintent 's Hospital I

Melllotl

Ischaemic heart disease Coronary atherosclerosis Diahetes, acute stress

Lack of oxygen to the brain

9.1

Commeuls/Recommeutlalions

Coroner

... that the new operation procedures in respect to hobbles and restraint belts be adopted.

Coroner

In terms of the communication difticultics at handover between the PMSOs and the Outpatients Department l note that following this incident a new procedure was introduced at the prison which required all urgent re!l:rrals to be committed to writing with appropriate requirements to record identifying factors. This is to be commended and would obviate a recurrence of the confusion which occurred in this case.

Commissioner's Independent Inquiry

9.2 That a formal handover procedure/referral form be formulated and agreed between Forensic Health Services and the Office of the Correctional Services Commissioner for implementation in public prisons.

9


CommentslllecommendtlliliiiS

Coroner

A lesson learnt by Corrections from difficulties associated with the management of Garry David was the 'need for the development of a comprehensive release preparation strategy during the latter stages of his sentence'.

In order that we reduce the risk to those individuals who have the disorder and for the overall welfare and safety of our society it is important that all relevant government (and other) agencies, professions and individuals working in this very difficult area cooperate and strive to find better solutions. This now appears to be happening in a far more coordinated way. And it is important that the work continue

I

10


12.

Name

DAVIES John Date.· 0610711996 Location: 1/M Prison, Ararat

Metlwtl

Ischaemic heart disease Coronary atherosclerosis Chronic

obstructive airways disease

DRINKEN George Andrew Hanging Date· 3011011997 Location: Port Phiflip Prison

Commems/Recommettdlltiou,~

COI?E lnqui1y

t 1. I That arrangements be made with the Ambulance Service to have an ambulance attend the prison and all available staff be instructed in the location and purpose of equipment carried on the vehicle.

112 That an up to date emergency contact list for the SESG be provided to the prison Control Room.

J Consider laying gravel to provide a driveway to the Unit.

114

1L5

11.6

That Ararat management circulate a memorandum to all staff, reinforcing the specific requirements of Director's Instruction 1.12 (3.1) (Deceasell Prisoners), in relation to crime scene management.

That a memorandum be circulated to staff nt HM Prison Ararat, reinforcing the procedures outlined in Director's Instruction 1,12 (3.2) concerning the responsibility for informing other persons and agencies following a death in custody,

That the Medical Officer be asked to provide an 'on call' roster to both prisons in the Region to ensure that only one phone call needs to be made when emergency medical assistance is required.

Independent Report Recommendations

12.1 That a form of covering be devised and fitted over the horizontal iron bars covering the windows inside each cell at Port Phillip Prison, such covering to allow light to enter the cell, and to enable the window to open either at the top or bottom, to allow air into the cell.

! 2.2 That in the single cells oft he Units at Port Phillip Prison, an alternative type of shower screen or curtain be litted, or the present shower screens modified so that there is no section of the screen which can be used as a "llnnging Point" The present shower screen may be able to be modified so as the present upright metal bars tin ish at the same ileight as the shower screen, in a stand-alone manner, or that a plastic type shower curtain be fitted into a runner in the ceiling of the cell

I!


Name Metlwd

DRINKEN George Andrew

(Continued)

12.3

C ommeu ts/R ecommeu da tl 011 .1·

That the shower nozzles in each cell be replaced with a nozzle that would break when force is applied to it. The present shower nozzles have an angle on them so that it restricts what could be placed around it, but I believe something as thin as a shoelace could in fact hold fast at the present time.

12.4 That consideration be given to the present handle on the inside of the door, so that it is recessed into the door, and does not protrude into the cell.

12.5 That electrical appliance cords in the cells be shortened so that there are none that would be long enough to form a neck noose

12.6

12.7

12.8

12.9

12.10

12.11

12.12

12.13

That trap openings in cell doors be kept closed other than at times when a prison officer is present.

That on day shitt, there is always two prison officers on duty in each Unit at Port Phillip Prison, and if there is a requirement for activity outside the Unit, such activity be performed by a Gencnd Duties member.

That during the Muster Count, all prisoners be instructed and made to stand outside their cdl. In the event of a prisoner refusing to leave his cell, First Response be called, and the prisoner charged.

That General Duties Officers be designated a specific Unit to attend for the Muster Count.

That during training, prison officers participate in mock situation exercises, particularly in the tinding of a prisoner hanging in a cell, and then actually physically participating in the documented response actions

That during their training, prison ofticers be taken to the Coroners Court Mortuary, to view deceased persons.

That during their training, prison officers be taught the correct manner of CPR and each officer personally participate in the methodol0gy.

That each prison officer be issued with a "Blood Pack", and be instructed to carry it whilst on duty.

12


Name

DRINKEN George An drew

(Continued)

Metl1od Commellts/Recommeutlatiaus

12.14 That for the first three to live days of active duty as a Unit Oflicer or General Duties Ontcer, prison officers have a supervisor or experienced member to work with, to ensure they perform their duties in the correct numncr.

12.15

12.16

12.17

!2.!8

12.19

12.20

12.21

12.22

12.23

That all of!icers in their training phase participate in all aspects of the training, and complete the training course bdore being trained for specific tasks, such as the Control Room, unless it can be guaranteed the of!icer would only participate in the specialised form of work.

That the training component involving "Deaths in Custody" -"Suicide and Scll~Harm" be examined to ensure every possible aspect is covered, and ofliccrs arc totally conversant with their priority tasks.

That the "Aide Memoire" card be issued to each prison officer, and that they be instructed to carry it whilst on duty.

That between six and twelve months of completing their training, new prison officers be given a two day refresher course on specific topics, having participated in the prison environment.

That prison officers working specific areas, such as St Paul's and St John's, be totally briclt:d as to the running of the establishment, in order to be able to correctly give adYice.

That there be a Telephone 13ook in St Paul's and St John's, to record incoming and outgoing calls, such book to be separate from the Appointment Book.

That on the discovery of stress or exceptional emotion in a prisoner, the Unit Oniccr notify the control Room, and a record be kept of such instances, with the Control Room Officer checking with the Unit Officer and Supervisor on a regular basis.

That if a prisoner shows excessive signs of emotion or stress, the Unit Oflicer regularly checks on such prisoner during his shift, and a record kept for the information of on-coming shifts.

That and

officers be made aware of the diflt:rences in job descriptions of the prison psychiatrist and psychologist, permitted medical authority.

13


Name

DRINKEN Gcorge

(Continued)

Metll od Commeu ts/R ecommeut/(l(iOI/S

12,24 That prison oflicers be made aware that when medical professionals are "On-Call", they are available for genuine requests, and should be called loc

1225

12,26

12,27

12.2!1

12.29

That consideration be given to changing the role ofthe Duty Manager, in Emergency Order No, 3- Deaths in Custody, so that he becomes the Site Commander, and another senior otlicer be designated to taking charge of the Control Room,

That any request from a prisoner for medication be passed to a member of the medical sta!T for consideration, such decision not to be made by non-medical personnel, also that such request and response be recorded.

That after every incident of note at the prison, a structured de-brieling session be held, with all participants being required to attend, <UJd detailed notes of the session being taken, Such de-briding records should be k~pt in the Truining Wing or with the Intelligence Section.

That during training and any refresher course, emphasis be placed on the aspect of Crime Scenes, and the requirement to keep them secure and sterile,

That in tire event of a serious incident in t1 Unit, all prisoners be locked down at the earliest pnssihk time. ln the event of a prisoner being involved to the extent of requiring to be intervkwed, counsdlcd, or dwgcd, he should be placed in the nearest suitable cell, alone.

14

Coronial and Death Inq,uiry Recommendations - continued

3,

Name

EDW A!UJS Brian Thomas

Date: 0210311~98 Locatwn: HM Prison Bar won

Metl!otl

Apparent murder

Commellls/Recommelltlitlions

CORE Inquiry

13, I That an immediate audit be conducted to identify and remove any unauthorised knives found in stall' amenities and administration areas within prisoner accommodation units and that Local Operating Procedures be amended to include the requirements of Section 32(1)© of the Corrections Act 1986 in respect to taking unauthorised articles into u prison,

13,2 That the Operational Review Unit formally investigate the issue relating to the failure to report the missing knife by both SPO Flew and PO Ba!lis and that the findings and recommendations arising from the investigation be provided to the Director, Prison Services for consideration,

That the Chkf Executive, in conjunction with the Oflice of the Correctional Services Commissioner, negotiate variations to the existing Service Level Agreement, aimed nt providing greater Jkxibility fnr prison 1111111ngers to implement regimes for managing prisoners who arc dismissed !rom work, who r~fuse to work or who arc subje~:t to short term medical conditions, including reduced out of cell hours where applicabk,

That the Chief Executive, in conjunction with the Commissioner, Correctional Services, develop protoco!s to address issues arising from the unusual or unexpected transfer of prisoners to CORE prisons which are outside the normal sentence management process. The aim of the protocols will be to give prison managers greater t1cxibility in implementittg approprime protection, management or medica! regimes for prisoners thus transferred, in consultation with the Director, Sentence Management

15

Coronia! and Death Inquiry Recomflilendations - continued

!4.

Name

FILl PS Michacl Date · 19/0311998

Location : St Vincent's Hospital

Method

Complications following suicide attempt 07/03/1998

Comments!Recommeutlatiotts

lndependenl Report Recommendations

I 4. I That lh~ upright metal bars supporting the shower screens in the cells and bathrooms ut Port l'hillip Prison be terminated at the height of the shower screen, in order to remove the hanging p(lints at the shower screen, plus where the extension of the metal bar attaches to the ceiling.

14.2

14.3

14.4

That the metal soap-holders attached to the walls in the shower area of the cells be removed, and replaced with holders that would break off if any weight were attached tu it.

That on their return to prison tram Court, those pri~on~rs having received a sentence, be examined by a psychologist before being locked-down for the night.

That afier the death uf a prisoner, and 1llier relatives have been notilied by police, lh~ prison authorities write Ill the prisoner's next of kin with words of condolence, and nominating an orti~cr !'rum whom further information may be obtained

16


15.

Name

GARTII Kcvin Graham

Date: 25105//995

Location : !-!M Prison Loddon

Method

llanging Coroner

I Commellts!Recomnlelltllltiolls

15.1 In the document the Onice of Corrections makes a number of recommendations which, if implemented, might assist in preventing the recurrence of such further events. The recommendations are endorsed by this Court and where not fully implemented at this time, steps to fully implement are urged as a matter of priority.

Commissioner's independent Inquiry

15.2 That the Prison Manager remind all staff of the requirements contained in Prisons Operations Branch Memorandum "Action following the death of a prisoner" dated 10 January 1994.

15.3 That the Prison Manager ensures that unit supervisors on a daily basis account !'or their unit's emergency accoutrements eg intervention knife. The results of these inspections should be recorded in the unit diary.

17


16.

Name

GREENAWAY, Robert lames Date: 2311111992 Location: HM Prison Pentridge

Method

Hanging

Comments/Recommendations

Coroner

16.1 Mr. Greenaway's medical history should have been known to the Director of the Oflice of Corrections

16.2

16.3

16.4

16.5

16.6

As an interim measure, all prisoners received at Pentridge Management Unit be referred for assessment by a health care professional and that pending this assessment the prisoner is observed at least half hourly at irregular intervals on a 24 hour basis

The Correctional Services Division knew or should have known was a suicide risk

The cell itself was unsuitable

The cell also contained a towel rail at a height of 1.6m, an obvious hanging point

l believe in this instance the height and positioning of the towel rail was ill considered in view of Robcrt lames Greenaway's past psychiatric history

OR&/ Inquiry

16.7 It is recommended that all staff who may be responsible for transferring prisoners to the PMU be instructed to ensure that full details of the circumstances leading to the transfer are provided to the officer in charge of the unit at the time of transfer.

16.8 It is recommended that as an interim measure, consideration be given to : adding the categories of Attempted Suicide and Self Mutilation to other alerts currently on the PIMS Prisoner Profile Enquiry Screen; including a special computer generated lace sheet placed at the front of both the Master and Green (institutional) Classification File which would highlight to custodial staff appropriate warnings (eg escape, suicide, protection etc); providing guidelines to staff on the use of the above alerts.

!8

Coronia! and Death Inquiry Recommendations · continued

Name

GREENAWAY, Robcrt lames (Continued)

Metfwll Commellfs/Recommendlttlous

OR,~ I inq11iry (con/inued)

16 9 lt is recommended that: PMSO Robineau be formally counselled for failing to make a reasonable attempt to distribute prescribed medication to Robert Greenaway on the evening of 23 November 1992.

In line with recommendations made in the attached Health & Community Services report, that further discussions occur with H&CS on the possibility of qualified nurses dispensing medication in the Coburg Complex.

The Governor reviews the reception information documents provided to prisoners at the PMU and ensures that restrictions and entitlements of all regimes are clearly specified.

A review of the PMU observation procedures be conducted. This review should include consideration of physical changes necessary to enable custodial staff to effectively carry out observation.

As an interim measure all prisoners received at the PMU be referred for assessment by a health cure professional and that pending this assessment the prisoner is observed at least half hourly at irregular intervals on a 24 hour basis.

16.10 It is recommended that the Governor: reviews the PMU reception procedures with u view to ensuring that all prisoners receive the basic entitlements

consistent with the applicable regime as soon as possible following transfer to the unit. Ensures that all staff pertorming key emergency management roks wear the yellow Emergency Management

Tabards to ensure that they are readily identifiable. Ensures that when an incident occurs which requires the attendance of external persunucllagcncics, a Liaison

Officer is assigned to all entry points.

16.11 It is recommended that the General Manager, Prisons Operations establishes a process which ensures that post incident debriefings for all staff and response agencies are conducted

19


17.

Name

IIATIIERLEY Donald George Date: 1411111991

Location: liMP Pen/ridge

Method

llanging

Commellts!Recommelltlutiolls

Report Recommendalions

17.1 That Review and Assessment Committees for '13' Annexe be charged by an Assistant Supervisor ofCiassitication given the specialist nature of the Unit

17.2

17.3

17.4

17.5

That each prisoner's placement within '13' Annexe be reviewed by the Review and Assessment Committee every three months to ensure the continuing appropriateness of the placement and to ascertain the prisoner's progress within the unit.

That consideration be given to the attendance of professional staff nl Review and Assessment Committee meetings within specialist units such as '13' Annexe to provide advice on the placement of prisoners in the more contentious cases

That A/SPO Buwalda be reminded of the correct practices to be follow~d wh~n calling for urgent assistance.

That regular exercise and training on dealing with emergency incidents be conducted for staff within srccialist units such as '13' Annexe.

17.6 That a Hellwig intervention knile be located within a secure lockable cabinet be issued with a key to the cabinet.

'13' Annexe and that each officer

17.7

17.8

That procedures be developed in relation to the referral/requests l(lr psychological services and that these procedures be consolidated with other procedures relating to initiating contact with other professionals (e.g. medical, psychiatric).

That the Acting Senior Psychologist and the Assistant Directors of Prisons Strategic Services and Program Development and Implementation in consultation with relevant Gnvcrnors be responsible for the establishment of procedures to ensure that relevant inl<mnation is exchanged bdween case workers, rsychologists and other rrofessional staff and tor the information to be recorded on the prisoners Individual Management Plan.

20


8.

Name

IIUGHES Quinn Anthony Date: 0310811993 Location Metropolitan Reception Prison

Method

Epilepsy

18.

Commellts/Recommelldtltions

OR& I Report Recommendations

That the present system of Prison Medical Support Officers distributing medication be replaced with a medication system whereby State qualified nurses dispense medication in a proper and accountable manner.

18.2 That the Governor of the prison issue the K Division Second Watch Senior Prison Officer with unit cell keys when conducting early morning trap musters.

18.3 That the Governor's Instruction 57/9 I Access to Prisbners Cells During l st and 2nd Watches be amended to ensure if a cell needs to be opened during a Watch period inK Division then :

the Senior Prison Ofticer of the watch in K Division is the onicer who carries, and is responsible for, the cell keys; staff who enter the units do not carry a key which operates the entrance night lock to the units; in emergency situations the Senior Prison Officer must immediately notify the CPO of the emergency but need not wait for the CPO before entering a unit and opening a prisoner's cdl.

18.4 Other safeguards contained in the Governor's Instruction should remain, such as : securing firearms and excess keys; more than one staiTbeing present when opening a celL

21


19.

Name

IRWIN Adam Courtney Date: /611211997

Location: Port Phi/lip Prison I

, Met/wtl

I langing

C ommenlll R eco m mend alio 11 s


19.1 That a form of covering be devised and titled over the horizontal iron bars covering the windows inside each cell at Port Phillip Prison, such covering to allow light to enter the cell, and to enable the window to open either at the top or bottom, to allow air into the cell.

19.2

19.3

19.4

19.5

19.6

19.7

19.8

19.9

That an alternative type of shower screen or curtain be titted, or the present shower screen modi tied so that there is no section of the screen which can be used as a "Hanging Point." The present shower screen may be able to be modi tied so as the present upright metal bars tinish at the same height as the shower screen, in a stand-alone manner, or that a plastic type shower curtain be titted into a runner in the ceiling of the cell.

That the shower nozzles in each cell be replaced with a nozzle that would break when force is applied to it. The present shower nozzles have an angle on them so that it restricts what could be placed around it, but I believe something as thin as a shoelace could in fact hold fast at the present time.

That consideration be given to the present handle on the inside of the door, so that it is recessed into the door, and does not protrude into the cell

That electrical appliance cords in the cells be shortened so that there me none that would be capable n!' l(ll'lning a neck noose.

That during training, prison officers participate in mock situation exercises, particularly in the finding of a prisoner hanging in a cell, and then physically participate in the documented response act ions.

That during their training, all Prison Officers attend at the Mortuary, Coroners Court, to view deceased persons.

That during training, an emphasis be placed on the correct method of CPR.

That all present serving Prison Officers be given a brief refresher course in the correct method of CPR, specilically in regard to placing the body on a hard surface

22

Coroninl and Denth Inquiry Recommendations - continued

20.

Nu me

IR WIN A dam Courtney (Continued)

KEATING Paul John Date. J0/0811997 l.ocation: HM Prison Beech worth

Met/toll

Hanging

19.10

19.11

19.12

Commellls/Recmtm!emlutious

That the training component involving "Deaths in Custody" "Suicide and Selt~llarm" be examined to ensure every possible aspect is covered, and the Officers are totally con¥ersant with their priority tasks.

That after every incident of note at the prison, a structured de-briefing session be held, with all participants being required to attend, and detailed notes of the session be taken. Such de-briefing records should be kept in the Training Wing or Intelligence Section

That during training, and any refresher courses, emphasis be placed on the aspect of Crime Scenes, and the requirement to keep them secure and sterile

CORE Report Recommendations

20. I The con11rmationthat a prisoner is present in his cell.

20.2 The requirement that the prisoner verbally acknowledges the officer's presence.

20.3 That officers responsible for intervention knife.

these musters are to carry cell keys, a portable radio, and an

20.4 That the General Manager, Northern Region Prisons, reinforces with senior staff at Beechworth Prison, the need to comolete Emergency Control Centre logs, ree.ard!ess of the location selected to be used as the ECC.

20.5 A found will be cut down mt:uuuc::ty and a check made for vital To limit crime scene contamination, the noose and knot are to remain undisturbed if death is absolutely certain.

20.6 If death is not certain, the officer first on the scene will call for assistance and proceed with emergency first aid until relieved by medical statT.

23


21

Name

KELL Y Russdl Edward

Date: 1511/11993 Location: f/M Prison Pen/ridge

Method

Compression of the neck

Commellts/Recommendlltions

OR&/ Inquiry

2 Ll Prison Operations Branch introduce procedures for early morning trap musters to be conducted in all Units with single cell accommodation :

prior to prisoners being let out of their cells; with at least two officers present; with the officers carrying the cell keys, an intervention knife and a radio; with the result of the count being relayed to the officer responsible for reconciling the prisons master muster; subject to the security precautions alluded to in this report.

21.2 That Prisons Operations Branch provide guidelines in the 'Emergency Coordination Centre Manual' to assist Operational Commanders in determining when it is appropriate (i) to formally close the ECC and/or (ii) to scale down the operations of the ECC.

21.3 That a system be established and enforced which ensures that when a prisoner is transferred the Individual Management File accompanies the prisoner to the receiving accommodation unil.

21.4 That copi~s of in~ident reports be plac~d on the prisoner's IMF as soon as possible atlcr the incident.

2 I .5 That Prison Operations Branch establish a group or nominate a senior ofiiccr to review the circumstances of prisoner deaths and to develop strategies to address any common issues and trends.

24


22.

N11lne

KOERS Rodney David Date: 19/03/1998 J.ocalion · /'on Phillip Prison

Metll01l

Hanging

22.

22.2

22.3

22.4

22 5

22.6

22.7

22.8

Cmnnumts/Recommeullulimu


That the upright metal bars supporting the shower screens in the cells at Port of the shower screen, thus leaving no hanging poim

Prison be terminated at the height

That the hanging points such as the horizontal metal bars across the cell windows, and also the cell inside door handle be modified.

That where a prisoner is placed on the "At Risk" or "Special Watch" Lists, he should be interviewed within 12 hours of such SASI! Team Meeting.

That a list of those prisoners on the "Special Watch" and "At Risk" Lists for each individual Unit be issued to the Supervisor of those Units, at the commencement of each shift, for relaying to each unit orticer, for their information.

That where prisoners are still at Cour1, or absent from the prison at the time of medication dispensing, that on return to the prison they be tnkcn to St Joilns Unit and the mcdicntion dispensed, prior to returning to their cdl.

That there be a Telephone Message Book in the Officers' Stntion at St .lohns llospital Unit lllr the recording of messages in/out concerning requests for services, including medication.

That all messages concerning prison or prisoner activity received in the Control Room be documented

That at the completion of all serious incidents at the prison, including suicides or suspected murders, there be a comprehensive de-briefing conducted with all relevant parties being present, and that such details be documented.

25


23

Name

LAFFEY Col in John

Dale, 24110/1997

Location · HM Beechworth Prison

Met/loll

Hanging

23.

Comuwltts!Recommeuillltiom

CORE lleporlllecommendations

That Beechworth Prison develop procedures to ensure that prisoners who present concerns w stall' in respect to their condition, be placed under observation conditions whilst they remain in their cells. These procedures must

provision for a full exchange of relevant information during shift changes.

' 23.2 The confirmation that a prisoner is present in his celL

23.3 The requirement that the prisoner verbally acknowledges the officer's presence.

23.4 That officers responsible for conducting these musters are to carry cell keys, a portable radio, and an intervention knife

23.5 That the General Manager, Northern Region Prisons, reinforces with senior staff nt Beechworth Prison, the need to complete Emergency Control Centre logs, of the location selected to be used as the ECC.

23.6 A found will be cut down To limit crime scene contamination, the noose and knot are to remain undisturbed if death is au>u'u'"'Y

23.7 If death is not certain, the officer first on the scene will call for assistance and proceed with emergency first aid until relieved by medical staff.

26


24,

Name

LEWJS Lcisa Joy

Dcue: 30105/1994

Location ,' St Vincent's Hospital

Metflod

Hypoxic organ damage following prolonged cardiac respiratory

C ommeut.s/R ecomme ut! a tious

OR&! Inquiry

24, I That Prison Operations Branch reassess the present incident procedures checklist to recognise that prisoners, in nddition to stan; should receive post-trauma events debriding;

arrest 24,2 That formal and informal count processes be exarnined by Prison Operations Branch on a statewide basis (including revised arrangements at Fairlea) in terms of frequency and adequacy of practices employed, Toxic effects

of drugs

243 That both local management instructions and post orders at Fairlea rcllect the requirement that staff should regularly perambulate throughout all areas of the prison to check on safety and security issues,

24A That the feasibility of upgrading the PIMS Visits Module be examined in order to provide for the automatic !lagging of a visitor's prison or community based corrections history,

27

Coronia) and Death Inquiry Recommendations .. continued

Name Mefluul

25. MARlNUCCl Anthony

Toxic

Dale · I 511111993 effects of

Local ion .· Melbourne drugs

Remand Cemre

25.

25.2

Conmumts/RecoJmuentlations

Coroner

Also in spite of the deceased's drug history there were no flags on his file indicating the necessity to search his visitors.

"despite the prisoner having been at the Melbourne Remand cemrc in excess of 3 months his individual case management had not commenced". Although this is a problem that requires attention l am not able 10 determine whether improved management of the deceased would have changed the outcome.

25.3 Consideration should be given to enabling as much information as practicable being made available to the family (or other relevant party) at an early stage.

25.4 Clearly a situation which permits a visitor, refused a contact visit for 011e prisoner, to almost immediately visit another without stringent controls is not satistitctmy.

25.5 lt is important to isolate and search all relevant witnesses who arc (or may reasonably be) suspected of being involved in the incident

25.6 The importance of both immediate and regular attention to case management plans for each prisoner cannot be underestimated. lt is also important to ensure regular review of each prisoner's case management to identify areas that may need attention.

011&/'s Enquiry

25.7 That the efforts of staff involved in the resuscitation auempt of prisoner Marinucci be formally acknowledged.

25.8 That PO King in particular be commended for his sustained efforts in attempting to resuscitated prisoner Marinucci.

28

Coronia! and Death Inquiry Recommendations -continued

Name

MARINUCCI Anthony

(Continued)

Metllotl Commeut.I!Recommem/(ltitms

OR& l's Enquiry (continued)

25.9 That the General Manager, Prisons Operations Branch reinforces to Governors the importance of activating the Emergency Coordination Centre in accordance with the requirements of the Prisons Operations Branch Emergency Coordination Centre Manual.

25.10 That Prison Operations Branch include a section in the Emergency Coordination Centre Manual which emphasis the importance of the Operational Commander to monitor and manage the operations of the entire prison in addition to managing the primary incident occurring within the prison from the prison's Emergency Coordination Centre.

25.11 That Prisons Operations Branch reinforce to all prison staff the procedures in relation to preservation of evidence and isolation or suspects/witnesses

25.12 That when selecting an appropriate visitor identitieation and registration system, Prisons Operations Branch wke into account tl1e shortcomings oflhe current visitor identilication system, outlined in Section 5.1 of the Marinucci report.

25.13 That the Governor: I. Implements the searching strategy as recommended on page l 0 of Attachment 2 from the Melbourne Remand

Centre Security Audit Report, April 1993. 2. Ensures that staff record in all search registers all information necessary to allow for proper search analysis to be

conducted.

29


Name

MARINUCCI Anthony

(Continued)

Metlwtl Commeuts/Recommelltlatiotls

OR& /'s Enquiry (conlinued)

25.14 It is recommended that the Individual Management Plan Policy and Procedures Manual 'Remand Prisoner' section be revised so that ·

Pages I to 4 of Section 2 of the Individual Management File are completed by the reception/assessment unit officer in order to identify the prisoners immediate needs on reception. Any changes to the prisoners circumstances from the initial reception at the Metropolitan Reception Prison and the later reception at the receiving prison and action taken are recorded on page 16 of Section 2 (progress notes). The allocated Unit Supervisors, Mainstream Units of the prisoner being in the unit : 0 reviews and compares Section 1 and Pages of the Individual Management File to ascertain

uny changed prisoner circumstances; 0 familiarise themselves with relevant tile notes; 0 tiuniliarise themselves with Section 4 of the Individual Management Fik; 0 conduct a formal interview with the prisoner and develop his/her local plan by working through pages 1 to

4 of Section 2 and completing pages 5 and 6, Section 2 with the prisoner. Unit Managers and prison management conduct quality control reviews of Individual Management Files.

25.15 To avoid confusion regarding the completion of an Individual Management File (regardless of prisoner status) it is recommended that the word "sentence" in the heading "Sentence Plan • Reports" (Section 2, pages 18 and 19 of the Individual Management File) he changed to rdlcct a review process for every prisoner regardless nf status.

25.16 lt is recommended that the Governor, Melbourne Remand Centre : Ensures that the Individual Management File monitoring/quality control responsibilities of the Governor of the Prison, Assistant Governor (Accommodation), Chief Prison Officers, as well as other Senior Managers at the prison, are formally defined; Ensures that staff duties and procedures Individual Management Files are formally dbcumented, and that these duties/procedures arc consistent wilh the Individual Management Plan Policy and Procedures Manual; Makes readily available to all staff the documentation and the manuals relevant to the maintenance of the Individual Management File; Considers retaining the working party as a permanent committee. The role of this committee would include monitoring the Individual Management File implementation and quality control, whilst providing staff with ongoing direction and support, and the identification of training and resource needs.

30


26.

Name

MOSS Thomas William

Date· 1910511995

Location : Melbourne Remand Centre 1

Metllotl

Hanging

Commellts/Recolllllll!llllatitms

Coroner

26.) Of the recommendations implemented, the two most signi1icant are that each prisoner is allocated a case worker responsible for his case management within the Unit and that there is a regular audit of a prisoner's Individual Management Pile, ensuring the file is properly maintained by the case manager.

26.2 However, as there is some correlation between previous episodes of self harm and suicide and a "two outer" placement can be an effective suicide prevention option, such assessment should be undertaken.

Commissioner's Independent Inquiry

26.3 That the manager of the prison ensure that in the future an incident log is maintained at the incident scene.

26.4 That Prisons Operations Branch amend current procedures in relation to the conducting of' incident debricls Ill include the requirement that an incident debrief' be chaired by a Senior Corrections Manager who is independent of' the incident and the prison

31


27.

28.

Name

NEVILLE Christopher Leslic

Date· 0310211991

Location : f!M Prison Won Wron

NGUYEN Quang Huy

Dale : 15/05//991

Local ion: A Division, HMP Pen/ridge

Metluul

Ischaemic heart disease Coronary artery thrombosis

Stabbing

27.1

27.2

I '

Commettts/Recommenilatiolls

OR&/ Report Recommendations

That the Director of Prisons issue a Jeller of commendation to Prison Officers Foster, Jones and llaughie for their swift response and action in attempting to resuscitate Prisoner Christopher Neville.

That the Director of Prisons arrange a formal tile note for the Master Classilication File of Prisoner John Powell which recognises the caring approach shown to a fellow prisoner and his swift action in seeking assistance following the collapse of Prisoner Christopher Neville.

27.3 That the relevant Assistant Director of Prisons be responsible for 'chairing' a prison death incident debrief and that this should occur within 24 hours of the incident.

OR&/ Report Recommendations

28. I That as a matter of urgency the Director of Prisons seek to establish a joint OCC/Victorian Police Working Party to examine the options available to improve the communication of offender information/intelligence from the Police to the OOC at the time a prisoner (sentenced or remand) is received into Prison.

28.2 That where a Reception Officer becomes aware of matters relating to the management and safe placement of prisoners, details of these matters must be communicated through the Governor Classification to the OIC of the Prison Division in order to ensure the appropriate management of the Prisoner.

2!U That the Governor of Classification (or his delegate) be responsible lor ensuring that upon the transfer of any prisoner from or between Divisions/prisons, that the prisoner Green File is included amongst those documents transferred with the escorting officers. The OlC of the Division/Prison should be required to confirm acknowledgement of the Green File on receipt of the Prisoner.

32

Coronia! and Death Inquiry Recommendations · continued

Name

NGUYEN Quang Huy

(Continued)

Method Commeurs!Recommetttlations

Report Recommendations (Continued)

28.4 That as part of the Prisoner Reception/Orientation process that the OIC of the Prison/Division or his delegate ensure that the Prisoner Green File is perused fix the purpose of noting relevant information/warnings in respect to the prisoner at the time of reception.

28.5 That upon the reception of any Vietnamese prisoner, that a delegated reception officer make telephone contact with a member of the Police Asian Division for the purpose of obtaining information/intelligence relevant to the management of the prisoner, i.e. gang membership, known enemies within Vietnamese community, circumstances or prisoner demeanour etc.

28.6 That classification maintain an approach of dispersing Vietnamese prisoners as widely as possible throughout the system, and avoid aggregations of more than 5 Vietnamese and situations where Vietnamese prisoners are left "I out" at a location.

28.7 That an expanding role be sought for the existing Community Corrections Onicer to involve him in the initial assessment and induction of all Vietnamese prisoners on initial reception.

28.9 That links be developed and maintained between OOC and relevant agencies, e.g. Police Asian Division to monitor trends and track changes in Vietnamese criminality, Vietnamese Community groups to increase knowledge of the criminal justice system and to develop community based options for bail supervision and management

28.10 That consideration be given to the appointment of a Vietnamese Of!icial Visitor or volunteers.

33


29.

Nmue

NGUYEN Quang Huy

(Continued)

PARKIN SON Matson Harold

I

Date : 09!0311992

Location: HM Prison Bendigo

Met hot/

Stabbing

Cmmm:uts/Recammeutlatious


28.21 That staff in location consistently dealing with Vietnamese prisoners be provided with cultural awareness training.

28.12 That incidents involving Vietnamese prisoners be monitored- particularly those involving ofticers, to isolate and establish all contributing factors

OR&! Report Recommendations

29.1 That the Director of Prisons acknowledge prisoner Simon Egan's (CRN5003) assistance in the form of n letter in rendering first aid assistance to a fellow prisoner following the assault on prisoner Matson PARKlNSON and that a copy of this letter be placed on his Master Classification file.

29.2 That the Governor of IIM Prison lkndigo liaise with Lodtlon Prison in order to become familiar with the Lodt!on contingency plan to provide staff resources in the ;;asc of an emergency at llendigo.

29.3 The Governor Emergency Management Unit consider the development of similar formal emergency response contingency plans for other Victorian prisons.

29.4 That all Governors ensure that following a serious incident occurring within the prison all stall' are notified of !he incident and issued specific instructions where appropriate.

1 29.5 That the topic "preservation of evidence" be included as a separate component of Prison Oflicer recruit training and that

this matter be referred to the OOC Training Steering Committee by Prisons Division.

34


Name

PARKINSON Matson Harold

Metltod Comments!Recommemflllilms


29.6 That the Emergency Management Unit review: • The current practice of OOC staff photographing crime scenes, relevant evidence and/or victims injuries;

* The need to provide formal guidelines or procedures and training in relation to this practice.

29.7 That pending the outcome of discussions at the Governors Conference regarding amendments to Operational Order l.l Infection Control and Prevention the Governor ensure that all officers reporting for duty sign a register that states that they have the emergency aid equipment pouch in their possession and the contents are complete.

29.8 That the Governor and Deputy Governor at Bendigo Prison be formally reminded: * That when a traumatic event occurs within the prison that professional staff are requested to attend in order to

provide a traumatic event debriefing service for staff; • That the attending Post Trauma Counsellorls attending the prison are provided with the names of nll stnff nnd

prisoners involved in the incident.

29.9 That all tools issued to prisoners in the industry area arc to be recorded in the Industry Tool, Material ami Equipment Register;

29.10 Material and Equipment Registers used in the are to be

29.11 That separate dated inventories for kitchen knives and the prisons maintenance tools {including those items held in the store) be established and maintained

35


30.

Name

PROSSER Paul N1ark

Date: 14112/1996

Location : D Division, MRP Coburg

Metltotl

!lunging

Comlllelll.'i/Ret:o/1/llle//tlatioll.'i

Coroner

30.1 I recommend that upon reception of any prisoner into a correctional facility who has a known psychiatric history, that all reasonable efforts be made to have available to the assessing nurse the full medical history pertaining to any previous admissions into psychiatric facilities within the prison system. Pending the receipt of same, which should be arranged in the shortest possible time, any placement should be provisional only with appropriate safeguards, including where necessary (and with the prisoner's consent) a direction to prison staff in relation to any particular needs or concerns about the prisoner's mental state.

30.2 I recommend that procedures be introduced to facilitate and enable family and other visitors to relay any concerns they may have about a prisoner's mental and emotional state to prison authorities so that appropriate monitoring and assessment may take place. One has to be impressed by the enormous efforts made by Mandy Humphries to call attention to her perception of her brother's plight. There should have been a simpler mechanism in place to enable and even encourage visitors (like Tracey Perkins) to raise concerns with the confidence that they would be attended to

CORE Inquiry

30.3 That the General Manager, Coburg Prisons Complex, reinforce the need for the Prison Governor, Field Commander and Liaison Ofticer to wear the designated tabards during prison emergencies irrespective of the time the incident occurs

30.4 That the General Manager, Coburg Prisons Complex, be reminded of the emergency procedure requirements relating to the need to conduct incident debriefs within live days of the emergency occurring.

30.5 That the General Manager, Coburg Prisons Complex, implement procedures to ensure that all staff are issued with Emergency Aid Pouches and carry them throughout their tour of duty, that the contents are regularly checked and that staff are aware of the procedures for replenishing the pouch contents.

36

Coronial and Death Inquiry Recommendations · continued I

Name Met/tot/

3!. REAR DON Craig Anthony

Intravenous drug

Date : 1410411996 abuse (heroin)

Location : lJM Prison Barwon

31.1

Cmttllleltls!Recommeuthtlimu·

Coroner

I am of the firm belief such certificates should not be issued unless a prisoner has returned a negative result each time he or she is tested

31 .2 That the Manager HM Prison Barwon review the level of random IOU and "targeted sampling" with a view to increasing the level of sampling in both categories, consistent with levels at similar prisons.

313 That the Statewidc Collator review the level of visitor searching at Barwon, I

31.4 That the Manager HM Prison Barwon reviews the suitability of employing !DU prisoners as kitchen or food preparation workers at this prison

31.5 l! is almost irresistible to suggest thnt nmuom testing or prison orliccrs should be introduced. If such searches were introduced they should be organised in conjunction with a senior police omcer ami a legally qualilied medical practitioner should also be present This should of course include persons who are responsible for providing services to the prisoners

31.6 I also believe that the use of sniiTer dogs should be investigated to see if they might be used at all entrances of the prison to help detect drugs and perhaps act as a deterrent to those who may he templed to introduce drugs.

31.7 That the recommendation made in the report of Governor Alan Clive Scaite be implemented.

31.8 That the DATE I Program conducted by HM Prison 13arwon be critically reviewed, and in particular a "Certilicate of Completion" not be issued unless a prisoner has remained drug free whilst completing the course. Indeed, a certilicate should never be issued for the successful completion of any drug program unless a prisoner has remained drug free.

37


Nmne

REAR DON Craig Anthony

(Continued)

Method Commellts/Recommemlatiolls

Coroner (continued)

3!.9 That the provision of Sections 44 and 45 of the Corrections Act 1986 be used to ensure that all persons who are permitted to enter a prison are randomly and thoroughly searched for drugs. In implementing such a policy a discreet program should be introduced to search prison ofliccrs in a way that I have previously discussed.

31.10 That a more intense program be introduced to randomly test IDU offenders at Barwon Prison to monitor the extent of drugs within the prison system.

31.11 That the use of X-ray equipment and perhaps snitTer dogs be used to detect drugs within the prison system and that the details of such use be centrally recorded.

CORE Inquiry

31.12 That Barwon Prison Management implement procedures for conducting prc kt out trap counts that inclttdc itS a minimum:

the confirmation that a prisoner is present in his or her cell; the requirement that the prisoner verbally acknowledges the orticcrs presence, and

31.13 That the Manager, HM Prison Barwon circulate a memorandum to all staff, reinforcing the specilic requireme!lls of Director General's Rule 1.12 (3.1) Deceased Prisoners), in relation to crime scene management.

31.14 That Barwon Management ensure each staff member has a lmninated copy of the incident procedure checklist colour code of suitabk size to be carried in an ID wallet and include this item as purt of the normal hag and puss check randomly conducted at prison locations.

31.15 That emergency procedures at HM Prison Barwon be amended to rdlcct the need for slaiT louse the lnddcm J>roccdurc Checklist colour code system when alerting staff to a prison emergency.

38


32

N11me

REARDON Craig Anthony

(Continued)

REGAN Paul Stanlcy

Dote : /3/041/995

/.ocation: HM Prison Pen/ridge

Metllod

Hanging

Cmmlll!ltt.v/Recomllll!lltllltiolls

CORE Inquiry (continued)

31.16 That the Manager of 1-lM Prison Barwon implement procedures to ensure that all staff are issued with Emergency Aid Pouches and carry them throughout their tour of duty.

31.17 That the Manager, HM Prison Barwon review the level of 'random IOU' and 'targeted sampling' with a view to increasing the level of sampling in both categories, consistent with levels at similar prisons.

31.1 & That the Statewide Collator review the level of visitor searching at flarwon and if necessary, recommend strategies designed to increase visitor searching levels to those of comparable prisons.

31.19 That the Manager, HM Prison Barwon reviews the suitability of employing !DU prisoners as kitchen or food preparation workers at this prison

Commissioner's Independent Jnquil)i

32.1 To ensure that prisoners cells can be opened as quickly as possible in emergency situations it is recommended that the Prison Manager ensure all staff arc familiar with correct key procedures.

32.2 That the Prison Manager reinforces to staff the importance of the requirement to use the emergency code in order to alert staff of the nature of the incident and ensure that the appropriate contingency plan commences as soon as possible,

32.3 That the Prison Manager ensures that watch stall' carry their radios at all times during their watch period.

39

Coronial and Death Inquiry Recommbndations - continued

33.

Name

ROBINSON William James

Dale : 13/04/1996

Localion : HM Prison Pen/ridge

Method C o m men tsl R eco 111 me 11 tl at io 11 s

Incised

wounds to CORE inquiry neck

33.1 That the Coburg Prisons Complex Management reinforce the procedures for conducting pre let-out trap counts that include as a minimum :

the visual confirmation that a prisoner is present in his cell; and the requirement that the prisoner verbally acknowledges his presence to the onicer/s.

33.2 That the General Manager, Coburg Prisons Complex, circulate a memorandum to all stall, reinforcing the specitic requirements of Director General's Rule 1.12 (3.1) 'Deceased Prisoners' in relation to crime scene management and preservation of evidence including the requirement to bnsure that the location is not disturbed by unauthorised persons

33.3 That the Director's Instruction currently being developed for 'at risk' prisoners, includes provision that when staff are alerted to a prisoner contemplating suicide, immediate steps will be taken to report this information to the appropriate medical professional for assessment and follow up. Additionally, any information relating to a prisoner contemplating suicide will be noted in the Unit Diary and include details of the subsequent psychological referral.

33.4 That the Coburg Prisons Complex Management develop an action plan to address issues arising from the incident debrief not dealt with by the Inquiry, for forwarding to the Director, Prison Services.

40

Coronial and Death Inquiry Recommendations · continued

34.

35.

Name

SHEA John Arthur

!Jate . 5 May 1990

Location: HMP

TELLEY, Dean Russell

Date · 25109/1992

Location. fl M Prison Araral

Metflod

Acute

Myocardial infarction

Hanging

34.1

C omme11ts/R ecammeutltltians

OR&! Recommendations

The nex( need for equipment which will address the concerns raised in respect to protection for staff required to apply urgent mouth to mouth resuscitation as well as other emergency situations.

34.2 The need for access to specially marked tape similar to that used by the Police to identify the crime scene.

34.3 That all Gov~rnors to be instructed to include the updated prisoner death incident checklist in the incident management folders provided to all staff of th~ rank of senior prison officer and above.

Coroner

35. I I recommend the Department of Justice undertake a review of what documents and/or information (including !'reSentence Reports, Community I3ased Orders and Intensive Corrections Order, Assessments, and Psychiatric and/or Psychological Reports), should accompany a prisoner to goal for the purpose of assisting in the assessment and management of the prisoner.

OR& !Inquiry

35.2 It is recommended that the Director of Prisons establish a working party to examine ways of improving the provision of pertinent prisoner information to OOC at the time of a prisoner's reception into custody.

35.3 It is recommended that the Assistant Director of Prisotls (Program Development und Implementation) in consultation with the Senior Psychologist conduct an initial assessment of OOC's current practices and procedures for certain categories of prisoners considered most at risk and that the lindings of the study be discussed with the Director of

41

Prisons to determine future action.

Coronial and Death ~nquiry Recommendations - continued

N11me

TELLEY, Dean Russell

(Continued)

Metllod Commeuts/Recommemllllions

OR& I (Continued)

35.4 The Inquiry Team recommend that a formal review of cell property be undertaken under the direction of the Assistant Director of Prisons (Operations and Prisoner Services) with a view to establishing minimum standards across all prisons

35.5 lt is strongly recommended that the Supervisor of Classitication should ensure that minutes of these meetings in the future reflect both a full summary of the evidence presented along with an explanation of the reasons for a recommendation/non recommendation and that these reasons be clearly spelt out to the prisoner at the Review and Assessment Committee meeting.

35.6 lt is recommended that Governors, in accordance with the Department's Traumatic Events • Debrieting Policy, be reminded that all officers involved in any serious incident should be contacted by a professional post trauma counsellor.

35.7 1t is recommended that all Governors be formally reminded of the need to conduct post incident dehrietings for all staff and response agency personnel involved in an incident in accordance with the Director of Prisons memo.

42


36.

Ntillte

TU Vienh Chi

Date : 0410111998

Location : Pori Phiflip Prison

Metllotl

Suspected

drug

overdose

Comments/Recommewltlfilms

fndependent Report f?ecommendations

36.1 That when conducting a Muster Count, all prisoners be instructed to stand outside their cell, in order to ensure their identity and pl1ysical condition; also that the Standing Operational Procedures be amended to ensure this procedure is implemented

362 That when a Muster Count is being conducted, and the Oflicer conducting the count does not know the prisoner, that the prisoner be made to call out his name for checking pmposes.

36.3 That after receiving contact visits at the prison, all prisoners be strip-searched, in order to prevent contraband being introduced into the prison

36.4 That when there is a requirement for activity outside a Unit, such as transporting a prisoner elsewhere in the prison, a General Duties Officer conduct such transporting, leaving the Unit Officers at their station.

36.5 That all serving prison officers be informed once again of the need to secure Crime of Incident Scenes at the earliest possible time, and that this matter be reinforced in the training phase.

36.6 That officers be officially instructed that then performing CPR, the victim be on a hard surface, such as a tloor, as opposed to using a bed

36.7 That when Muster sheet details are transferred from the (hand-written) hard copy to the computer, that the cell, as well as the Unit occupied by each prisoner, be recorded for any future enquiry.

43


37.

Name

TU Vienh Chi

WALTON, Wayne Garry

Date: 2310211993

Location: HM Prison Pen/ridge

Metltml

Hanging

36.8

36.9

36.10

36.11

Comrrreuts/Recommeudatltms

Report Recommendations

considcrution be given to allowing a drive-way to be limncd around the inside pcrimcler of the prbon, in order that essential services, or reinforcements may be moved quickly and cl'Jkicntly to any part of the prison, with a gate into each Unit area or facility, thus requiring only one lock to be opened.

That as an alternative to the previous Recommendation, consideration be given to the gates into the Unit areas inside the prison being electronically operated from the Control Room.

That after any death, attempted suicide, or incident of note, a structured debriefing be held, and details recorded to examine how such incident was responded to, and for any future inquiry.

That nil operational prison ort!cers, whether casual or full-time, b~ 1\illy trnincd in llrst-aid prnc~durc~ prior l<l working in the Units.

Coroner

37.1 It is recommended that consideration be given to implementing procedures that would ensure communication of relevant information from medical staff to custodial staff, so that all prisoners can be classified, not only according to correctional needs, but also their mental and

37.2 That it is not possible to prevent the determined individual from inflicting self harm. To deprive prisoners of normal bedding, clothing, eating utensils, entertaining facilities and to maintain them under constant observation in order to prevent such an occurrence, would create an inhumane and unworkable environment

OR&/ Jnqwry

37.3 That the matter of health care staff providing advice to custodial staff when there are indications that a prisoner may be at serious risk be raised at a meeting of the Corrections Health Board in order to develop appropriate protocols for the exchange of information

44


Name

W AL TON, Wayne Garry

(Continued)

Method

Hanging

Comments/Recommendations

OR&! (Continued)

37.4 That Prison Operations Branch in conjunction with health and welfare staff develops procedures which ensure that when health and welfare professionals attend at special purpose units, they personally assess prisoners' needs.

37.5 That the Governor HM Prison Pentridge: ensures that a review of PMU observation procedures is conducted including an examination of the feasibility of conducting observation of all prisoners at the PMU on an ongoing basis. This review should include consideration of physical changes necessary to enable custodial staffto effectively carry out observation; as an interim measure, ensures that all prisoners received at the PMU continue to be referred for assessment by a health care professional and that pending this assessment, the prisoner is observed at least half hourly at irregular

• intervals on a 24 hour basis.

37.6 That the external review of special units includes consideration of the issues raised by this report in relation to observation procedures.

37.7 That the Governor, HM Prison Pentridge: arranges for a review of cell fittings and equipment in the PMU to assess the potential for these items to be used by prisoners to self harm;

• considers the need for risk reduction measures ( eg short appliance cables).

37.8 That the results of this review be considered by Prisons Operations in terms of the applicability to other special purpose units throughout the state

37.9 That the Governor HM Prison Pentridge: liaises with the Director, Forensic Health Service on the need to establish guidelines in relation to initial information to be provided to medical staff/PMSOs by custodial staff in the event of a medical emergency;

issues an instruction to staff which details these guidelines.

45

Coronial and Death Inquiry Recommendations · continued

38.

Name

WALTON, WayneGarry

(Continued}

WHITAKER Gk:nn Jason

D12te: 07!09//994

Location: NM Prison Bendigo

Melllotl

lleroin toxicity

I I

Commellls!Recommemlllllml.~

OR& I inquiry (Continued)

37.10 That the Genl!ral Manager, Prisons Operations: • formally reminds all Prison Governors of their responsibilities in relation to conducting post incident debrielings; • considers the development of a post incident management procedure that includes provision for:

0 the General Manager to appoint a delegate who will liaise with the Governor of the Prison to ensure that a formal debriefing occurs within 24 hours of the incident;

0 either the General Manager or the delegate to chair the debriefing; 0 all staff and external agencies involved in the incident to be invited to attend the debriefing.

37.11 That subject to acceptance of the above recommendation, the Governor, Emergency Management Unit ensures that the revised post incident procedures are included in each prison's Emergency Procedures Manual.

Coroner,

38. I Those shortcomings related to the number of prison oflicers required to pcrfonn the early morning "trap" muster and the providing of counselling support following such an incident, at the earliest possible opportunity.

38.2 lt is recommended that the prison authorities remain vigilant in their efforts to detect and deter drug adivity within the prison system, with the continuation of random and targeted searches being conducted.

OR&/ Inquiry

38.3 ... post trauma counselling service is provided more swillly in the future.

38.4 ... that Prisons Operations Branch will stress the importance of the requirement lhr prison management to activate the Emergency Coordination Centre when responding to an emergency

46

Coronial and Death Inquiry Recommendations ~ continued

39

Name

WHITAKER Glenn Jason

(Continued)

ZAMMITI'aul

Date: 09!0611993

Location · 1/t'vl Metropolitan Reception Prison

Metlwtl

Hanging

3Rt

39.

Commettts/Recommelldatiou.\·

OR&! Inquiry (Continued)

As Kelly, ic : "Prison Operations Branch introduce procedures for early morning trap musters to be conducted in all Units with single cell accommodation :

prior to prisoners being let out of their cells; with at least two o!Ttcers present; with the ofliccrs carrying the cell keys, an intervention knife and a radio; with the result of the count being relayed to the omcer responsible for reconciling the prisons master muster; subject to the security precautions alluded to in this report.

Also: staff carrying cell keys while conducting early morning trap musters would not carry keys which operate the entrance locks to the wing/unit; all night shift firearms would be secured in the prison's armoury.

OR& I Inquiry

That the Governor or the prison issue conducting early morning trnp musters.

K Division Second Watch Senior Prison Ortkcr cell keys when

39.2 That the Governor's Instruction 57/91 Access to Prisoners Cells During [Stand 2nd Watd1cs be amended ta ensure if a cell needs to be opened during a Watch period inK Division then :

the Senior Prison Officer of the watch in K Division is the ofticer who carries, and is responsible for, the cell keys; staff who enter the units do not carry a key which operates the entrance night lock to the units; in emergency situations the Senior Prison Ofticcr must immediately notify the CPO or the emergency but need not wait for the CPO before entering a unit and opening a prisoner's cell.

39.3 That the General Manager, Prisons Operations Branch, examine the extent to which the two previous recommendations regarding the issuing of cell keys during I st and 2nd Watches are applicable to other prison divisions/units.

47

Coronial1md Death Inquiry Recommendations - continued

N11me Met/u)(/

39 ZAMMlTPaul

Hanging

{Continued)

C ommeuts/R eco 11111/ell tlttl ious

OR& /ltlquiry (Continued)

39.4 That Prisons Opcmtions llranch issue an instruction to all Prison Governors that upon discovering a prisoner hanging, staff should immediately take the prisoner down and remove the hanging device from around the prisoner's neck and that resuscitation be attempted where applicable

39.5 That Prisons Operation Branch formally advise all prison Governors of the need to : purchase intervention knives and place them in accessible and secure locations for ready access by staff on a 24

hour basis; formally advise all staff of the purpose, location and correct use of imervention knives; issue officers conducting trap musters with an intervention knife.

39.6 That Prisons Operation Branch consult with the Medical Director, Forensic Jlcalth Service and the Victorian Ambulance Service rcgilruing the need lilr prison stall to contad the ambulance scrvic~ in the ev~nt of th~ apparent death of a prison~r.

39.7 That the Governor ensures that all oftic~rs working amongst the prisoner group arc issued with emergency aid equipment pouches at the beginning of their shifts.

39.8 Thatlh~ Governor issue an instruction that staff working in units in K Division be required to formally accoum for all accoutrements issued to that unit on a daily basis at the commencement of their shift.

39.9 That the Governor of the Prison ensure that in the event of a prison emergency that the prison's Emergency Co-ordination Centre be activated in accordance with the n:quiremenls of the Prisons Emergency Co-ordination Centre ManuaL

39.10 That the Governor ensures that all staff performing key emergency roles wear the yellow Emergency Management Tabards to enable ready idcntit!cation

39.11 That the Director-General's Rules Ll2 Deceased Prisoner Section 3.1 be amended to include the requirement that an officer upon discovering a prisoner apparently dead to check the prisoner for vital signs and if necessary altempt resuscitation.

48