Get documents about "Venue & Coroner
Shared by: qCx4u3
-
Stats
- views:
- 16
- posted:
- 5/19/2012
- language:
- Latin
- pages:
- 73
Document Sample
CORONERS’ RECOMMENDATIONS
AND GOVERNMENT RESPONSES - DECEMBER 2009 TO JUNE 2010
Made pursuant to section 82 of the Coroner’s Act 2009
Names of deceased included in this Report
AHMADI, E JAMAL (aka RAZA) A RANKIN S
CALLAGHAN, J JOHNSON, J SEMAAN, C
EAGLE, P KENNEDY, G SUPPRESSED NAME #1
ENGERT BLINN INNES AND MOORE LAWRENCE R SUPPRESSED NAME #2
FORRESTER MR MORAN, GJ SUPPRESSED NAME # 3
FORSTER MP MIDSON, PJ SUPPRESSED NAME #5
HOGAN, P MURPHY, M TUPOU, M
HOWLETT, C PELE, I WALMSLEY, DG
INFANT SWIMMING POOL DEATHS PHAN AU, I WILSON, PG
1
Name of Date, Finding Recommendations Recommendations Response
Deceased Venue & Coroner made to:
& File No.
rd
Rebekah Deputy State That Rebekah Anne Minister for Health That having regard to the Minister for Health 3 May 2010:
Lawrence Coroner Lawrence died on 20 following definitions of
1988/05 MacPherson December 2005 at St psychotherapy and counselling In December 2006 the NSW Parliament
Vincent’s Hospital from contained in a report by passed a range of amendments to the Health
8 December 2009 multiple injuries sustained Professor Margot Schofield Care Complaints Act and the Public Health
when she stepped off the prepared for the Psychotherapy Act to provide for the regulation of
At Glebe ledge of a second storey and Counselling Federation of unregistered health practitioners. The terms
window of her place of Australia (PACFA), funded by of the legislative scheme are broad enough to
employment at the Royal the Victorian Department of cover those who offer the type of counselling
Australian College of Human Services (DHS Victoria) or psychotherapy services raised as a matter
Physicians, Macquarie entitled Best Practice Self- of concern at the hearing. The key principles
Street Sydney, and fell to Regulation Model for of the legislative scheme are:
the pavement below whilst Psychotherapy and Counselling The incorporation in the Public Health
in a psychotic state. in Australia Final Report, dated (General) Regulation 2002 of a Code of
February 2008 at pages 15-16: Conduct for Unregistered Health
Practitioners. The Code incorporates a set
(a) DHS Victoria has defined of objective and clear standards against
“generalist counselling” as “the which to assess a practitioner’s conduct
application of and practice in the event of a complaint;
knowledge and a range of skill, A negative licensing system that allows
such as reflection, constructive action to be taken against a practitioner
confrontation and who fails to comply with the standards of
problem solving, with the gaol of conduct or practice set out in the Code;
reducing distress or harmful An independent investigator, the Health
behaviour and Care Complaints Commission (HCCC), to
improving quality of life, social receive and investigate complaints;
functioning and health, within the Power for the HCCC to issue both
context of an prohibition orders and public warnings
interpersonal relationship that is about practitioners who have failed to abide
designed to facilitate these by the required standards of conduct and
changes”; practice;
(b) DHS Victoria has also Offence provisions allowing for a person
suggested that “counselling” who breaches a prohibition order to be
seeks to: prosecuted through the appropriate court.
(i) provide relief from emotional The maximum penalty for an offence is
2
distress and its social $5,500 and/or 12 months imprisonment.
consequences;
(ii) promote longer term coping Some of the key standards set out in the NSW
with adverse circumstances, and Code of Conduct for Unregistered Health
(iii) reduce vulnerability to mental Practitioners and relevant to the issues raised
health and social problems in the in your inquiry into the death of Ms Lawrence
future; are that unregistered practitioners:
(c) the United Kingdom Council Must provide health services in a safe and
for Psychotherapy (UKCP) ethical manner, including
defines - by not providing health care of a type
“psychotherapy” as “the provision that is outside his or her experience or
by qualified practitioners of a training;
formal and - by providing truthful information as to
professional relationship within his or her qualifications, training or
which patients/clients can professional affiliations; and
profitably explore - by not making claims, either directly or
difficult, and often painful, in advertising or promotional material,
emotions and experiences. about the efficacy of treatment or
These may include services provided if those claims cannot
feelings of anxiety, depression, be substantiated.
trauma, or perhaps the loss of Must have an adequate clinical basis for
meaning of one’s the treatments they provide; and
life. It is a process, which seeks Must not financially exploit their clients.
to help the person gain an
increased capacity for Other important matters addressed in the
choice, through which the Code include that unregistered practitioners:
individual becomes more Must not claim to cure cancer and other
autonomous and self terminal illnesses;
determined. Psychotherapy may Must not attempt to dissuade their clients
be provided for individuals or from seeking or continuing with medical
children, couples treatment; and
families and groups”: Must not have an improper personal or
(d) the Schofield Report suggests sexual relationship with a client.
a composite definition of
psychotherapy Since commencement of the scheme the
and counselling as “talking and Health Care Complaints Commission (HCCC)
relationship-based therapies in has issued one prohibition order on a
which trained practitioner; placed conditions on the practice
professionals use theory, of one practitioner; and issued two public
3
research and practice-based statements about practitioners (including one
knowledge and skills with of the practitioners who had conditions placed
the gaol of reducing distress or on his practice).
harmful behaviour and improving
relationships, The HCCC has indicated that had the Code
quality of life social functioning been in place at the time of Ms Lawrence’s
and health, within the context of death it may, in response to a complaint, have
an interpersonal investigated the complaint within the
relationship that is designed to framework established by the Code.
facilitate these changes”.
16 However, in light of the concerns raised by
That consideration be given to this case and Magistrate MacPherson’s
the restriction by regulation of the recommendations, I have approved
provision of services such as amendment of the Code to incorporate the
those provided by Zoeros Pty.Ltd, following matters:
trading under the name of unregistered practitioners must not provide
PEOPLE Knowhow, and in services they are not qualified to provide;
particular the course known as and
The Turning Point and similar unregistered practitioners must not use
courses provided by other their possession of particular qualifications
organisations by:- to mislead or deceive their patients as to
(a) the introduction of a legal their competence or ability to provide
requirement:- services in particular areas.
(i) to have recognised tertiary These amendments are included in a Bill that
qualifications in medicine I intend to introduce to Parliament in the
(psychiatry), current session.
psychology, psychotherapy,
social work, nursing, welfare, I can also advise you that the Australian
counselling or other Health Ministers’ Council (AHMC) is currently
appropriate qualifications from an considering whether or not, in the context of
institution accredited by either the national health professionals registration,
Commonwealth a nationally consistent approach should be
or NSW Education Authorities (or adopted for regulating unregistered health
by an overseas course practitioners. NSW has expressed the view
recognised at the same that, given the NSW experience to date,
level in Australia) before AHMC should adopt a regulatory system
providing psychotherapy or modelled on the current NSW system and that
counselling services, incorporates the general principles outlined
irrespective of whether those above.
4
services are described as
comprising psychotherapy
or counselling, but excluding ad
hoc counselling or psychotherapy
as an incident
to providing other professionally
recognised services; or
alternatively
(ii) to have such qualifications as
a pre-condition for legally
providing
such services for payment or
other reward;
(b) the creation of a system of
registration and accreditation of
psychotherapy or counselling
services by one of the following
means:-
(i) seeking the inclusion of
psychotherapists and counsellors
in the
scheme for national registration
and accreditation of the health
professions which
is the subject of the Council of
Australian Governments (COAG)
Intergovernmental Agreement
between the Commonwealth,
States and
Territories, dated 26 March 2008;
or alternatively
(ii) the creation of a statute-based
scheme of registration and
accreditation of psychotherapists
and counsellors in New South
Wales; or
alternatively
(iii) the creation of a statute-
based mandatory regime of self-
5
regulation
of psychotherapists and
counsellors in New South Wales,
having regard to the
terms of the Schofield Report.
That for the purposes of
considering introducing the legal
requirements set out above and
for the
purposes of considering a system
of registration and accreditation,
as set out above, consultation
take place with the Royal
Australian & New Zealand
College of Psychiatrists, the
New
17
South Wales Psychologists
Registration Board, the Sydney
Branch of the Australian
College
of Clinical Psychologists, the
Australian Psychological
Society, the Australian
Psychology
Accreditation Council and the
Psychotherapy & Counselling
Federation of Australia.
FUTURE
– Next
response
6
TOP
Name of Date, Finding Recommendations Recommendations Response
Deceased & Venue & made to:
File No. Coroner
Ehalamreza Deputy State I find that Ehalamreza Minister for 1) I recommend that the Minister Hon Phillip Costa MP, Minister for Corrective
AHMADI Coroner Dillon AHMADI died at the Corrective Services direct that committees Services on29 November 2010:
1052/08 Metropolitan Special (18/05/2010) overseeing the installation of
18 May 2010 Programs Centre, Long security systems in NSW “I have been advised that Corrective Services
Bay Correctional prisons include senior NSW agrees with the six recommendations
At Glebe Centre, New South representatives from all arising from the inquest into the death in custody.”
Wales on 26 June 2008 affected facilities and from
by hanging himself in senior management at Full text of Minister’s response is to be viewed
his cell. regional area or above. here.
2) I recommend that the
Commissioner for Corrective
Services direct that all
decisions concerning
significant alteration to
security systems affecting
more than one correctional
facility be authorised only by
senior management at
regional level or above.
3) I recommend that the
Commissioner direct that all
such decisions be fully
documented.
4) I recommend that security
systems not be
“commissioned” (in the sense
of being made technically
operational) until all relevant
user guides or manuals have
been provided or updated
and all relevant staff have
been appropriately informed
7
and, if necessary, trained in
the use of the system.
5) If security systems extend
beyond one facility to
another, I recommend that, if
necessary, commissioning
takes place in clear stages of
which all affected parties are
kept informed.
6) I recommend that if a staged
commissioning of security
systems takes place in NSW
correctional facilities, those
parts of the system not in
commission are not turned on
except for testing or training
purposes, are clearly labelled
as non-operational until
commissioned, and staff are
kept informed as to the
current status of the system
and their responsibilities in
respect of it.
FUTURE –
Next
response
8
TOP
Name of Coroner Finding Recommendation Recommendations Response
deceased made to
Gordon John State That Gordon John Minister for Health That a toxicology screen, including The matter has been referred to the Department
MORAN Coroner MORAN died on July 23, blood alcohol level be performed by of Health’s Corporate Governance and Risk
1202/08 Jerram 2008, of complications of hospital personnel on all persons Management Branch to coordinate a response
blunt head injury and admitted to any hospital either on behalf of NSW Health. Transcript of Coronial
t
11 May 2010 coronary artery disease, seriously injured or killed as a result Inquest received 15 November 2010.
after a fall. of an accident in the workplace, as a
At Glebe matter of routine
FUTURE –
Next
response
9
TOP
Name of Coroner Finding Recommendation Recommendations Response
Deceased made to
Isaraelu Deputy State That Isaraelu Pele Minister for Health (1) I recommend that the Royal Alexandra Minister for Health November 2010:
PELE Coroner died on 18 Hospital for Children (Children’s Hospital
Dillon December 2007 at at Westmead) and the Sydney South Recommendation 1 – Supported
Blacktown Hospital West Area Health Service review their Recognition of signs of toxicity forms part of the
31 May 2010 NSW as a result of guidelines to provide for the assessment NSW Health policy ‘Emergency Departments
bacterial meningitis by senior staff of children presenting with Recognition of a Sick Child’ (currently under
that had not been any signs of toxicity before such children review).
At Glebe diagnosed by a are discharged;
number of The CHW Emergency Department (ED) guidelines
clinicians who have been updated regularly over the past 3 years
examined him. to reflect NSW Health Guidelines & guide
involvement of senior staff. CHW also advises that:
An increase in ED senior staff over 3 years has
increased the time when senior medical staff are
available to review patients.
Following the CHW Root Cause Analysis
investigation an ED Medical Unit (EMU) was
created (2008) next to ED to allow for extended
review of patients not well enough for discharge.
The EMU provides for longer patient observation
& for patient progress to be discussed with senior
staff.
The Paediatric ‘Between the Flags’ program being
developed will address recognition of a
deteriorating child, including some of the signs of
toxicity. Review by senior staff is triggered by
clinical prompts.
SSWAHS Area Critical Care Services (CCS) are
reviewing its ED practices to ensure all paediatric
presentations will be assessed by a senior doctor
before discharge.
10
Dept. of Health policy & program initiatives include:
‘Children and Adolescents - Guidelines for Care in
Acute Care Settings’ policy directive
‘Children and Adolescents - Admission to
Services Designated Level 1-3 Paediatric
Medicine Surgery’ policy
‘Children and Infants with Gastroenteritis - Acute
Management’ policy .
Paediatric clinical practice guidelines .
The ‘Between the Flags’ (BTF) program aims to
standardise processes for early recognition &
rapid response to deteriorating patients & includes
a ‘Standardised Adult General Observation Chart’
to record key observations likely to indicate a
deteriorating patient & assists in identifying when
a clinical review for sick patients or a “rapid
response” for very sick patients is required.
A BTF component is ‘Detecting Deterioration
Evaluation Treatment Escalation and
Communication in Teams’ (DETECT) training
package & includes e-learning & face to face
practical training. It was developed by clinical
experts to address the training needs of frontline
staff in the early recognition & management of
deteriorating patients. Training is being rolled out
state wide.
The Paediatric BTF program is under
development & replicates the features of the adult
program, including the standard observation chart,
rapid response & DETECT. Rollout of the
observation chart & education is expected later in
2010.
The Emergency Care Institute will develop a Sepsis
Pathway & Guidelines that include a review of
processes for all patients presenting to EDs with
signs of infection & sepsis, & an audit process of
Time to Antibiotics. The pathway & guidelines will
then be implemented by Health services.
11
(2) I recommend that the Children’s Recommendation 2 – Supported
Hospital and Area Health Service review CHW provides training for doctors in each rotation,
their guidelines to provide for annual & training on the detection of & tests for meningitis
training of clinical staff in Emergency is given to Triage Nurses. ED nurses complete a
Departments in relation to the detection of Dept. of Health e-learning module on bacterial
meningitis, including the possibility of meningitis.
children presenting without signs of
meningism and with normal vital signs SSWAHS has a program of in-service training for
and in relation to the appropriate tests to its junior ED doctors.
be conducted
Relevant state policies and programs include:
‘Emergency Departments Recognition of a Sick
Child’ policy
Paediatric clinical practice guidelines are
accompanied by on-line knowledge & evaluation
modules for staff
A paediatric companion to the ‘Rural Adult
Emergency Clinical Guidelines 3rd Edition’ is
being developed & to be used in rural settings
where no medical officer is immediately available,
& will include the immediate management of
meningitis.
BTF program & ‘Recognition and Management of
a Patient who is Clinically Deteriorating’ policy
standardise processes for the early recognition of
deteriorating patients.
The new Sepsis Pathway, to be developed by the
Emergency Care Institute (see Rec. 1) will also
incorporate strategies to address educational needs
(3) I recommend that the Children’s Rec 3 – Research study to be undertaken
Hospital and Area Health Service review Literature review & expert clinical consultation
the efficacy of CRP and other tests, (NSW Health Paediatric Clinical Practice Guideline
whether alone or in combination, in Steering Group Secretariat Feb. 2010) on the need
improving the diagnosis of serious to include C-Reactive Protein (CRP) testing in the
bacterial infection; revised paediatric clinical practice guidelines
indicated variability in the sensitivity & specificity of
12
CRP testing, with no consensus amongst clinicians.
The Dept’s Co-Ordination & Policy Unit also
recognized this lack of consensus on the use of
CRP testing for children & that the evidence for its
use in older children is sparse. UK guidelines
restrict the use of CRP to children strongly
suspected of being severely ill with a bacterial
infection. The utility of CRP as a ‘screening’ test for
ruling in bacterial infection is not high, with a
positive predictive value of only 60%. CRP to rule
out severe bacterial infection is not recommended
as it is not a good substitute for clinical judgement,
& in 10% of cases will produce a false negative
result.
The draft “Management of Acute Bacterial
Meningitis’ & ‘Acute Management of Fever’
paediatric clinical practice guidelines do, however,
suggest that clinicians consider CRP testing where
a child appears toxic.
Both CHW & SSWAHS noted the restricted value &
lack of consensus while acknowledging positive
aspects to the limited use of such testing.
CHW ED has a guideline on the use of CRP &
Procalcitonin tests in the assessment of a febrile
child. A research study to further evaluate utility of
the test has been granted ethics approval & will be
carried out as part of the Febrile Child Study over
the next 12 months. The results of this study &
other available literature will be used, as
appropriate, to inform local policy & guidelines.
(4) I recommend that the Children’s Recommendation 4 – Supported
Hospital and Area Health Service review NSW Health strongly supports providing information
the literature concerning meningitis which to parents/carers of children with a fever who are
they distribute to parents or carers on sent home, on what signs & symptoms to look for
discharge of children with any sign of that would indicate clinical deterioration & the need
13
toxicity. The document given to parents to seek further medical review.
ought to include clear, succinct
instructions on what to look out for and In response to ‘The Special Commission of Inquiry
the importance of returning immediately to into Acute Care Services in NSW Public Hospitals’
a doctor if signs or symptoms are seen; (Garling Inquiry) NSW Health is reviewing the
‘Discharge Planning: Responsive Standards
(Revised November 2007)’ & provided Health
Services with advice & information to develop local
guidelines. This includes:
All patients seen in a public hospital should
receive information on their treatment in the form
of a letter to take home.
This should include advice on their treatment,
medications & signs & symptoms that alert the
patient/carer to the need to seek further treatment.
CHW noted the ‘Recognition of Serious Illness in
Children’ Fact Sheet has instructions for families on
what to look for & when to seek help. It is given to
the families of children with fever in whom
meningitis & other serious bacterial illness is
possible, & is available on the CHW website.
The NSW ‘Infants and Children - Acute
Management of Fever Clinical Practice Guidelines’
& ‘Children and Infants Acute Bacterial Meningitis –
Acute Management’ will incorporate advice to
clinicians on providing a specific fact sheet to carers
when a child who has presented to ED with a fever
or a possible diagnosis of meningitis is discharged.
Other fact sheets are available to EDs, through all 3
Children’s Hospitals’ websites & are expected to be
given at discharge. Each Sheet includes an alert
section for parents/carers regarding worsening
signs & symptoms with reference to the parent fact
sheet in each of the paediatric clinical practice
guidelines.
(5) I recommend that the Children’s Recommendation 5 – Supported in Principle
Hospital and Area Health Service The computer programming work to include the
14
consider amending their triage question in the CHW ED Triage Assessment has
questionnaire to include an inquiry as to been completed with implementation shortly.
the number of recent attendances made
by children at hospitals or on General NSW Health ‘Recognition of a Sick Child Clinical
practitioners in relation to the same Practice Guideline’ (under review) includes a prompt
illness; for to consider risk factors that may make the child’s
presentation more urgent.
(6) I recommend that the Children’s Recommendation 6 – Pending conclusion of a
Hospital and Area Health Service review
consider amending their triage CHW noted a study on the use of a detailed
questionnaires to include an inquiry validated anxiety tool for parents of children
seeking to measure the degree of presenting to the ED identified high anxiety levels
parental concern; were related to parental experience, tiredness &
concern regarding blood tests & level of trust of
treating Dr. No relation to severity of the child’s
illness was reported, however taking note of
parental concern is included in the medical staff
orientation to the ED, as this is a basic tenet of
paediatric training.
Each of the NSW Health paediatric clinical practice
guidelines state that “parental anxiety should not be
discounted: it is often of significance even if the
child does not appear especially unwell.”
Parental anxiety may be examined as part of the
nationwide triage processes review with any
recommendations to be assessed at the review’s
conclusion. The matter will be referred to the ‘NSW
Emergency Care Taskforce’ for consideration.
(7) I recommend that the Children’s Recommendation 7 – Referred for further review
Hospital consider whether a measure of The tool was used temporarily in CHW ED as part of
‘parental concern’ can and should be built a research study looking at identifying children with
into its computerised diagnostic tool for a serious bacterial illness. Further work is required,
serious bacterial infection; including identifying the interface between the tool &
clinical practice. As noted in response to R. 6 there
is no accepted measure of parental concern & the
validity of a measure to assist diagnosis requires
more investigation. At the study’s completion a more
15
informed assessment could be made.
(8) I recommend that NSW Health Recommendations 8 and 9 Supported in
consider rolling out the Children’s principle subject to research
Hospital’s computerised diagnostic tool to As above, the study of the CHW tool is yet to
all NSW hospital Emergency determine if it is valid & whether it or a derivation
Departments; could be referred to the Emergency Care Task
Force before consideration by the state eMR ED
Application Advisory Group, for broader distribution
including non-hospital primary carers.
(9) I recommend that NSW Health As above.
consider ways in which the Children’s
Hospital’s computerised diagnostic tool
(or a suitable version of it) may be made
available to primary carers;
(10) I recommend that the Children’s Recommendation 10 – Supported
Hospital (if it has not already done so) Since 2009 CHW has a simulated training module to
consider developing a training module in practice the assessment of seriously ill children
which clinicians not only discuss but including those with bacterial infections. It has been
practice the diagnosis and treatment of evaluated as effective as it involves medical &
rare but serious bacterial infections in nursing staff in a team setting.
simulated settings.
NSW Health supports Child Health Networks which
fund Outreach Simulation Training for the
recognition & resuscitation of the unwell child
(11) I recommend that the Children’s Recommendation 11 – Supported
Hospital (if it has not already done so) CHW advised that this topic has been taught in
consider formally integrating the study of various fora at the hospital, & with the module being
cognitive bias and error into its teaching developed for regular delivery within CHW ED.
and training syllabus concerning
differential diagnosis. The Department will refer the module to the
Clinical Education and Training Institute (CETI) to
consider broader deployment.
16
FUTURE Further Training & Development Information
– Next A Hospital Skills Program (HSP) includes the recognition & treatment of meningitis in ED module.
response HSP targets non-specialised Drs working in EDs & other clinical areas.
HSP uses a range of training methods, including online, simulated learning & on the job training.
A paediatric module is being developed.
HSP supports the professional development of non-specialist medical staff but doesn’t replace the requirement for annual training on meningitis.
The Dept will raise the recommendations with CETI to ensure they are considered in the HSP & other training activities.
The national ‘Emergency Triage Education Kit’ was sent to all EDs to help provide better assistance to people presenting to EDs. A key chapter deals with the
diagnosis & treatment of children presenting to an ED in a critical condition.
‘The Transition to Emergency Nursing Program’, is a state wide education program to provide a:
focus on safe quality emergency nursing care
agreed standardisation of nursing skills for emergency care
clinically based hospital emergency program to encourage & promote the recruitment & retention of nurses to this speciality.
It will further develop the confidence & competence of new emergency nurses, enhance professional adjustment, assimilation into the workplace & ensure
quality patient outcomes.
17
TOP
Name of Recommendations
Coroner Finding Recommendations Response
Deceased made to:
Country Energy has filed a request in the Supreme Court seeking that the
HOWLETT Deputy That NSW Chief Medical That the NSW Chief Inquest be quashed and a fresh Inquest held.
Christopher State Christopher Officer Officer arrange for an
Coroner Howlett died audit of post mortem NSW Health 24 December 2009:
MacMahon on 23 October examinations undertaken
2007 at by Dr John Follent with a An audit of the post mortems performed by Dr Follent in the last five (5)
17 Burringbar view to ensuring that such years has been requested. A decision will be made on whether to extend
September NSW, through examinations are the audit pending the initial report.
2009 electrocution performed to the minimum
that occurred reasonable standard In addition to the audit, the Director-General, NSW Department of Health,
when he came expected of Government has written to Dr Follent informing him that his appointment as a Coronial
into contact Medical Officers Medical Officer is under review, pending the outcome of the audit. The
with live performing such work. Director-General has asked Dr Follent to desist from performing post
electrical mortem examinations whilst the audit is in progress. I would appreciate it
conductors in if you could inform the appropriate local coroners of these developments.
the course of Pending the outcome of the final report, requests for coronial post
his mortems from Tweed/Byron Local Area Command can be forwarded to
employment. the Coronial Medical Officers in Lismore.
FUTURE –
Next
response
18
TOP
Name of Date,
Recommendations
Deceased & Venue & Finding Recommendations Response
made to:
File No. Coroner
Suppressed #5 That [name Commissioner of 1. That Acting Sergeant Mark Hevers be
2897/09 State Coroner Suppressed] died Police commended for his bravery, compassion NSW Police Force response dated 15
Jerram on 2 October and all of his actions on 1 October 2009. December 2010:
Non publication 2009 from a gun
order under 20 May 2010 shot wound to the “Recommendation 1 – the Coroner’s
section 75 head, self remarks concerning Senior Constable
Coroner’s Act inflicted on 1 Hevers who held the rank of Acting
2009 October 2009, Sergeant in May 20190, have been
with the intent to forwarded to the Commander, Western
end his own life. Region, for consideration by that Region’s
Awards Committee.
2 – Relevant training material in the NSW
Police Force Safe Custody Course has
been updated to stress the need for police
to include information on mental health
and hospital admissions in antecedents,
when known.
The Brief Preparation Guide, which
assists police in preparing a brief of
evidence, is being amended to reflect
these developments.
19
2. That the Commissioner give Recommendation 2b – Consistent with
consideration to further training so that: existing NSW Police Force policy and
a) Police informants are aware of the procedure, the Local Area Commander,
desirability of detailing information Duty Officer or designated Operations
regarding mental health and hospital Commander is in command of high risk
admissions, known to them, in the operations. As such it is not the
antecedent section of Fact Sheets; and responsibility of the Negotiation Team t
b) any negotiating team give priority to the notify the subject’s next of kin, but rather,
early notification of next of kin in evolving the Commander’s. In any event, the next
high risk incidents and, in particular, of kin of a person involved in a high risk
before the release of any information to operation is notified as early as possible
the media. by police. “
FUTURE – Next
response
20
TOP
Date,
Name of Deceased & File Venue Recommendati
Finding Recommendations Response
No. & ons made to:
Coroner
Matthew Paul FORSTER My findings are that Hunter New 1. That in regard to pathology tests Minister for Health October 2010:
Matthew Paul Forster England Area sought by Emergency
1710/07 Deputy who was born on 5 Health Service Departments, the Hunter/New Hunter New England AHS has advised that an
State June 1982 died at 5 England Area Health Service electronic system for presenting aggregated
Coroner Bruntnell Street, implement a policy whereby patient results at the end of each shift will be
Mitchell Forster late on 11 or pathology staff are required investigated. A hard copy of the pathology results
in the early hours of immediately to report to the and a summary are checked and signed by the
11 June 12 August 2007 as Emergency Department any senior medical officer in the Emergency
2010 a result of pathology results which fall Department (ED) on a daily basis.
complications of a significantly outside the normal
At perforated duodenal range; HNEAHS advised that a system of telephoning
Glebe ulcer. 2. That the Hunter/New England the ED with results that fall outside of laboratory
Area Health Service implement alerts was in place at the time of Mr Forster’s
a policy whereby pathology staff admission; however his results did not fall outside
are required to ensure hard of the alert limits. The intent of these
copies of all available pathology recommendations is supported and will be
results are delivered to the achieved through progressive enhancements and
Emergency Department by the implementation of the Electronic Medical Record
end of each pathologist’s shift; (eMR) across the NSW health system.
3. That the Hunter/New England
Area Health Service implement Further NSW Health has implemented a
a policy whereby the senior statewide program to improve clinical handover
medical officer in the Emergency and the critical importance of handing over
Department ordering tests is responsibility for continuing patient care from shift
required to review all available to shift and between the ED and other clinical
pathology results by the end of areas. The implementation of this program
his/her shift across NSW is being monitored by the NSW
Acute Care Taskforce (ACT).
FUTURE – Next response A policy entitled Care Coordination: Planning from Admission to Transfer of Care is under development
21
TOP
Name of Date,
Recommendations
Deceased Venue & Finding Recommendations Response
made to:
& File No. Coroner
Glenn Deputy State That Glenn Kennedy died Commissioner of That the training package developed by The Commissioner of Police replied on
KENNEDY Coroner from multiple injuries Police and the Detective Chief Inspector Graeme McLeod 22/12/09:
MacPherson sustained when he jumped Minister of Police Abel in 1999 and entitled “Responding to
from the third floor balcony High Risk Incidents” be included in the “The NSW Police Force supports the
On 26 June of a unit at South Coogee, Mandatory Continuing Police Education recommendation and I can advise that the
2009 but the evidence does not Scheme. training package – Responding to High Risk
enable me to say whether Incidents (MO18) will be reviewed and
he intended to end his own updated as required, with a view to
life or not. reintroducing it as a core Mandatory
Continuing Police Education System
(MCPES) requirement in 2010/2011.”
The NSW Police Force has reviewed and
updated the training material and it will be
rolled out as a core MCPES in the 2011/12
financial year.
FUTURE
– Next
response
22
TOP
Name of Date, Recommend
Deceased & Venue & Finding ations made Recommendations Response
File No. Coroner to:
th
Deputy That [Name Minister for 1) That the Area Health Service leave Minister of Health 25 May 2010:
SUPRESSED State suppressed] Health policy for scheduled in patients be In response to the Recommendation (i) Northern Sydney Central Coast
#1 Coroner died on 19 reviewed and amended to formulate Area Health Service (NSCCAHS) has advised me that this
Dillon October 2007 a policy for the granting of short recommendation is supported and that the NSCC Mental Health Drug &
1939/07 from multiple unaccompanied leave Alcohol Leave Policy was reviewed in January 2010 and has expanded
injuries self the actions to be taken on granting (unaccompanied) leave for one to
Non 2 inflicted from 2) That the Minister consider four hours, including requirements to clearly document the rationale for
publication December falling from a reviewing current procedures at permitting short leave of a scheduled inpatient. Education for acute
order under 2009 bridge. Magistrates’ mental health inquiries in inpatient units regarding the amended policy and the responsibility of
section 75 light of the evidence presented that staff in granting and documenting leave and reviewing the patient on
Coroner’s Act At Glebe they may have a detrimental effect on return from leave has also been undertaken. The revised procedure has
2009 the therapeutic relationship between been disseminated to all staff and is available on the NSCCAHS Intranet
treating psychiatrists and scheduled website.
in –patients. In particular, that
consideration be given as to reducing The Mental Health Drug and Alcohol Office (MHDAO) of the Department
the adverse effects of doctors, in of Health has also advised that it supports this recommendation and that
effect, giving evidence against their while no Departmental policy or guideline outlines procedures for
own patients by providing legal managing graduated or short unaccompanied leave, many Area Health
representation for the doctors or by Services have included local protocols and policies on patient leave as
some other practical means. part of their discharge planning documentation. The matter will be
referred to the (NSW) Mental Health Clinical Advisory Council for their
3) That consideration be given by the advice and consideration of writing to the Area Health Services to ensure
Area Health Service to instituting they have policy provisions relating to the granting of short
‘debriefing’ of in –patients following unaccompanied leave.
an unsuccessful application for
discharge at a magistrate’s mental NSCCAHS and MHDAO have both similarly supported Recommendation
health inquiry. (iii). NSCCAHS will amend the Macquarie Hospital ‘Patients Attending
Magistrates and Tribunal Hearings’ Procedure to include the debriefing
of patients following such hearings. As with the Leave Policy, this
procedure was amended and disseminated in January 2010. MHDAO
has noted that whilst the debriefing of patients following magistrates’
hearings is often done informally, there is merit in developing procedures
to ensure that specific time is set aside to discuss the outcomes of such
hearings with the patient. Therefore, MHDAO proposes to write to the
23
Area Health Services asking that Area policies reflect this approach.
MHDAO additionally advised that page 62 of the current draft of the
‘Mental Health Act Guidebook’
http://www.health.nsw.gov.au/pubs/2003/pdf/mh_guidebook.pdf states
that “consideration should be given to enabling some kind of ‘debriefing’
to occur, preferably with someone outside the official framework of the
hospital, such as a friend, a consumer representative or an official
visitor.”
In relation to Recommendation (ii) both MHDAO and the Department of
Health’s Legal and Legislative Services Branch have advised me that
this recommendation is not supported. Firstly I note that the Legal and
Legislative Services Branch wrote to Magistrate Dillon on this matter
during the course of the inquest and that while he acknowledged this
correspondence in his findings, he appears to address only the final
aspect of the reasoning provided. The arguments forwarded by Legal
and Legislative Services Branch in opposing the recommendations are:
The lack of known studies or reports suggesting that the doctor–
patient therapeutic relationship is damaged due to the lack of legal
representation at magistrates’ inquiries;
That a mental health inquiry is not an adversarial process and ideally
should be conducted with as little formality as possible. The provision
of legal representation for medical practitioners may add to the
formality of the process and cause further distress to the patient;
Medical practitioners are not parties to magistrates’ hearings but are
there to provide evidence to the magistrate. As such, even if legally
represented, the practitioner would still be required to give evidence.
It is therefore unclear what role a legal representative would play as
they would not be able to give the evidence on the practitioner’s
behalf. The provision of legal representation for medical practitioners
would, therefore, not address possible adverse effects resulting from
the practitioner giving evidence.
Patients appearing before an inquiry have a right to legal
representation and it is hoped this representative clearly explains to
the patient the purpose of the inquiry, thereby ameliorating any
confusion or distress experienced by the patient;
With 11,971 magistrates’ hearings held in 2007* costs associated with
24
providing legal representation to medical practitioners at the hearings
would be significant and could divert funding from the provision of
frontline mental health services to patients
* Source: Mental Health Review Tribunal Annual Report 2007-2008
There is provision for a medical practitioner to make application to the
magistrate for legal representation if it is considered necessary or
appropriate for a particular case.
The Department’s Legal and Legislative Services Branch also consulted
with the President of the Mental Health Review Tribunal (MHRT) who
strongly opposed the legal representation of practitioners at magistrates’
inquiries. The President was of the view that legal representation would
distract from the matters being resolved at the inquiry, would not support
the therapeutic relationship between patients and practitioners, and
would add to the costs and length of the inquiries.
MHDAO has further advised that the Mental Health Act 2007 currently
allows for adjustment in certain circumstances of Tribunal procedure
both in relation to inspection of health care records (s.156) and the
evidence to be given in hearings (s.151). Information may be made
available to the patient’s representative but not disclosed to the patient if
it is for the benefit of the patient, or if the information may be harmful to
the patient or any other person.
In addition to the above such inquiries are now conducted by the Mental
Health Review Tribunal and not magistrates. Procedures for hearings
before the MHRT, including the mental health inquiries, are determined
by the Tribunal. Having regard to its extensive experience in conducting
similar inquiries under the Mental Health Act 2007 and the Mental Health
(Forensic Provisions) Act 1990, it has developed processes and
procedures that endeavour to ensure as therapeutic a hearing as
possible.
25
CEO Legal That, in the light of the evidence of Response received 28 January 2010 from Mr A Kirkland, CEO:
Aid this inquest, the training of Legal Aid
Commission Commission lawyers and private “Internal review of the relevant training has been undertaken. A
practitioners briefed to appear on preliminary review indicates that Legal Aid NSW provides regular
behalf of the Commission at mental training and support for solicitors who conduct mental health matters
health inquiries be reviewed. under grants of legal aid. Most recently, the 2009 Civil Law Conference
included a presentation by the Deputy President of the MHRT Ms M
Bisogni on the role of the legal representative in mental health matters.
The training is supported by a specialised induction process for new
solicitors and the availability of detailed publications on mental health
practice and procedure on the Legal Aid NSW Website.
Any deficiencies identified in Legal Aid’s approach to training solicitors in
mental health inquiries will be able to be addressed within the agency’s
existing resources.”
FUTURE –
Next
response
26
TOP
Name of Date, Finding Recommendations Recommendations Response
Deceased & Venue & made to
File No. Coroner
Matthew That Matthew Mater Hospital That the Mater Hospital On 20 July 2010 the Minister for Health advised:
Murphy Deputy State Murphy died on 3 Newcastle give consideration as to
100/08 Coroner December 2006 whether or not its “The policy identified in this recommendation is the NSW Health
MacMahon at the John “Suicidal Behaviour Statewide Policy Directive –Suicidal Behaviour – Management of
Hunter Hospital Policy” should be Patients with Possible Suicidal Behaviour (PD2005_121). This policy
19 March 2010 Newcastle. The amended to suggest that is under review by the NSW Health Mental Health, Drug & Alcohol
cause of death relevant information may Office. NSW Health acknowledges the vital role that families and
At Glebe was a bullet be obtained form the carers of people with a mental illness play in the lives of the person
wound to the family or other persons they are caring for and the important information they are able to
head which was without the consent of provide to clinicians to help with an assessment of that person.
self inflicted with the patient where it is Families and carers are ordinarily able to provide relevant background
the intention of considered that the information on a patient to medical staff at any time, with or without the
taking his own family or another relevant permission of the person they are caring for, without breaching privacy
life. person may provide the and confidentiality. Issues related to privacy and confidentiality only
medical practitioner with relate to the information staff can provide to families and carers about
relevant information that the patient without their permission, not the other way around.
the patient is unable or Existing NSW privacy legislation, and Department of Health’s suicide
unwilling to provide and risk assessment and management guidelines address the
there is a risk to the requirements of this recommendation when conducting a suicide risk
patient if such assessment. The NSW Health Privacy Manual (v2) (PD2005_593)
information was not provides advice around the limits on the use and disclosure of
available. personal health information.
Pursuant to the Health Records and Information Privacy Act 2002,
Health Privacy Principles 10 and 11 allow personal health information
to be used and disclosed in certain circumstances including where
there are reasonable grounds for believing that the use or disclosure
of personal health information is necessary to lessen or prevent
serious and imminent threat to the life, health or safety of the individual
or another person or serious threat to public health or public safety.
The NSW Health Consent to Medical Treatment – Patient Information
(PD2005_406) also provides guidance around issues where patients
27
are incapable of giving informed consent to the management of their
treatment.
The statewide guidelines, the Framework for Suicide Risk Assessment
and Management in Emergency Departments (NSW Department of
Health 2004) state that emergency department staff undertaking an
initial assessment should obtain collateral information from family,
accompanying persons, police, medical records and other health
providers as appropriate. It also states that the person’s family should
be informed of the assessment and any management plan if they are
in attendance at the emergency department, and should be contacted
at home before discharge if the person at risk lives with their family.
However, the Department of Health recognises that the legal issues
surrounding privacy and confidentiality may not always be clear for
health professionals presented with various and complex situations
when dealing with people with mental health problems. Accordingly
the NSW Clinical Advisory Council of the Mental Health Program
Council is considering the need for any further practical guidance for
clinicians in circumstances where it is important to seek or disclose
information to family or carers even when there is patient opposition.”
Hunter and New That training of medical The NSW Institute of Psychiatry (IOP) has been contracted to provide
England Area practitioners employed in education and training to Area Health Service (AHS) staff on mental
Health Service emergency departments health legislation. As part of the Project, the IOP is developing a
of hospitals emphasise website that will contain a module on mental health legislative
Mater Hospital the application of the requirements for staff of Emergency Departments (EDs) that have
Mental Health Act 2007, been gazetted as declared mental health facilities.
the powers of medical
personnel assessing
patients with psychiatric
conditions and the
circumstances in which
family and other relevant
persons should be
contacted without the
consent of the patient.
Commissioner of (1) That the training of NSW Commissioner of Police A Scipione APM on 25 August 2010 :
Police officers in dealing with
(24/03/2010) persons who are taken to “In relation to recommendation (1), the NSW Police Force provides
28
a hospital for a mental extensive education and training covering police responsibilities under
health assessment under section 24 (formerly section 22) of the Mental Health Act 2007,
the Mental Health Act including mandatory online training in relation to the Mental Health
2007 emphasise that Memorandum of Understanding between the NSW Police Force,
family members may be Ambulance Services and NSW Health.
able to provide important
background medical and Comprehensive mental health education and training is also provided
other information that to frontline police officers by the NSW Police Force Mental Health
would be helpful in the Intervention Ream (MHIT), which has developed a four day training
undertaking of a mental program in consultation with mental health experts. The program
state assessment and as provides police with an understanding of the Act and the Memorandum
such should, where they of Understanding. It also assists police to identify signs of mental
wish to do so, be illness and provides them with tools such as communication
encouraged to make strategies, risk assessment, de-escalation and crisis intervention
contact with the hospital techniques. A number of units of the MHIT program address the
to which the person is important role that family and carers can play in assisting police and
taken for assessment health care professionals with the management of persons
apprehended under the Act.”
Commissioner of That consideration be NSW Commissioner of Police A Scipione APM on 25 August 2010 :
Police given to whether or not
the handover forms “There is provision in the existing NSW Department of Health, Mental
NSW Department under section 22 of the Health Act 2007 section 22 Form for police to record information about
of Health Mental Health Act 2007 person who may be able to provide further information about the
should have space for patient. On 26 May 2010, the NSW Police Force Corporate
(24/03/2010) police to insert contact Spokesperson on Mental Health forwarded a Memorandum to all
details for persons who Mental Health Contact Officers and Region representatives,
may be able to provide emphasising the importance or recording information about patients’
further information about carers.”
the subject patient.
FUTURE –
Next
response
TOP
29
Name of
Date, Recommendations
Deceased & Finding Recommendations Response
Venue & Coroner made to:
File No.
Ivan PHAN AU Deputy State That Ivan Phan AU died NSW Police Force 1) That the matter NSW Commissioner for Police on 18 May 2010:
Coroner on 13 April 2002 at be referred to the
Milovanovich Surry Hills from Homicide Cold ‘The matter has been referred to the Unsolved Homicide Team
gunshot wounds to the Cases team. for attention and will be captured on the unit’s database and
chest, inflicted by a 2) That a reward be progressed at the earliest opportunity.
At Glebe person or persons offered for
unknown. information The NSW Police Force acknowledges that the offer of a reward
On 23 October concerning the can be a useful investigative strategy. Consideration is being
2009 circumstances of given as to whether the offer of a reward might assist in this
the death of Ivan particular matter’.
Phan Au.
FUTURE –
Next
response
30
TOP
Name of
Date, Recommendations
Deceased & File Finding Recommendations Response
Venue & Coroner made to:
No.
Jason Deputy State Coroner I find that Jason Commissioner of I recommend to the Commissioner of Police Commissioner Scipione on 24
CALLAGHAN Mitchell Callaghan died at Police Police that recognition be given to March 2010: The Deputy State
2345/08 Nepean Hospital the bravery and professionalism of Coroner’s recommendation has been
On 12 February 2010 Penrith on 30 July 2007 Leading Senior Constable Duane referred to the Protocol and Awards
of the effects of a self- Phillips and Constable Malcolm Unit of the NSW Police Force for the
inflicted gunshot wound Baker for the manner in which they provision of advice as to whether
At Glebe to the head but, discharged their duties on 30 July recognition of the officers’ actions on 30
whether he intended to 2007. July 2007 is appropriate and what form
take his own life, I am any such recognition should take.
unable to tell.
FUTURE – Next
response
31
TOP
Name of Date, Finding Recommendations Recommendations Response
Deceased & Venue & made to:
File No. Coroner
Shannon Deputy State Shannon RANKIN died on Minister for Fair 1. That action is taken The Division of Local Government will be updating
Abby-Rose Coroner 25 March 2006 at 14-18 Trading (or other to prohibit the its Backyard Swimming Pool webpage with links to
RANKIN MacMahon Head Street Forster. The Minister with inclusion of an relevant Office of Fair Trading information.
cause of her death was responsibility for the active main filter
503/06 At Glebe (and drowning, which occurred regulation of the drain in the floor of On 19 July 2011, the Director General, NSW
parts Taree) following her becoming design and spa pools in future Department of Finance and Services, Mr M Coutts-
entrapped on the cover of construction of pools constructions and Trotter, advised:
the main drain of the spa and spas in NSW 2. that media action
On 16 February pool within the apartment be taken to inform “In relation to Fair Trading, the matter was
2010 complex known as the the public as to the considered by the NSW [Products Safety
Sevan Apartments. Her potential dangers Committee, which is made up of product safety
entrapment was due to the associated with experts from business, medical, consumer and
significant pressure that active main filter Government backgrounds. Following ongoing
resulted from a blockage in drains in the floor of deliberations, the Committee produced a report with
the main drain that spa pools. a number of recommendations including that spa
occurred during the process 3. That action is taken pools should be required to comply with the
of the pebblecreting of the to require the requirements of the Australian Standard AS1926.3
wall and floor of the spa certification of in respect of outlet systems and covers.
pool during its construction pools and spas as
being in To support the recommendations of the Coroner,
compliance with Fair Trading also developed and launched
statutory and other guidelines for consumers which provide warnings
building and advice on ways to help avoid entrapment on
requirements, as suction outlets such as active main drains.
well as being safe
for proposed use, Fair Trading does not set building standards and
by an appropriately codes, deal with development approvals or handle
qualified and certification matters. The Department of Planning
independent expert has a representative on the Australian Building
prior to the pool or Codes Board. Additionally the Building
spa being handed Professionals Board, which is an independent
over for use by Board (but comes under the jurisdiction of
occupants of the Planning), handles certification issues and
property on which it complaints.
32
is constructed.
4. That action be These recommendations are outside of Fair
taken to ensure Trading’s jurisdiction and require the action and
that where a pool input of both the Minister for Local Government and
and/or spa forms the Minister for Planning. Letters were forwarded to
part of a property the Minister for Local Government and Planning on
development, an 16 March 2010 to formally bring the Coroner’s
occupation recommendations to their attention.
certificate not be
issued by the
relevant Principal
Certifying Authority
unless and until
that Authority has
satisfied himself or
herself that the pool
or spa has been
constructed in
accordance with
relevant statutory
and other building
requirements and is
safe for proposed
use.
FUTURE –
Next
response
33
TOP
Name of
Date, Recommendations
Deceased & Finding Recommendations Response
Venue & Coroner made to:
File No.
Camille Deputy State Coroner That the deceased, Camille Nassib Semann NSW Police I recommend that Mr A Scipione PSM, Commissioner of
SEMAAN Mitchell died on 1/9/1996 at 36 Martin Street Commissioner the NSW Police Police on 17 August 2010:
1778/96 Roselands, NSW as a result of a single (05/05/2010) Commissioner
6 April 2010 gunshot wound to the face, head and neck but consider a “Consideration is being given as to
I am unable to determine the manner in which monetary reward to whether the offer of a reward might
At Glebe those injuries were sustained or inflicted. information leading assist in this particular matter.”
to a conviction.
FUTURE – Next
response
34
TOP
Name of Date,
Recommendations
Deceased & Venue & Finding Recommendations Response
made to:
File No. Coroner
35
SUPPRESSED State That Commissioner of 1. That the Department of Corrective On 18 July 2011, Commissioner Ron Woodham
#2 Coroner [SUPPRESSED] Corrective Services review the systems and PSM responded as follows:
Jerram died on 21 May Services protocols in place for inmates known to
2007 at a be at risk, to determine whether these “ (1) A complete review was undertaken by two
ON 3 June Correctional Centre presently provide for a coordinated and officers from Corrective Services NSW (CSNSW) of
Non publication 2009 in NSW sometime proactive management plan for such the organisation’s approach to managing inmates at
order under between 17.00 inmates (including involving Correctional risk of self harm and suicide. This review also took
section 75 hours on 20 May Officers and mental health professionals) into consideration all recent coronial
Coroner’s Act At Glebe and 21 May 2007 particularly following a release or recommendations relating to procedures and
2009 as a result of discharge from a RIT protocol. policies associated with risk intervention. Tis review
hanging himself generated a detailed discussion paper which
with the intention of included a number of options for consideration by
taking his own life. CSNSW.
An expert review has now been commissioned by
CSNSW following on from the preliminary review.
This will comprehensively examine the risk
assessment protocols and management procedures
for those inmates known to be at risk of self harm or
suicide. The expert was formerly employed with
CSNSW as the Executive Director of Offender
Services and Programs. The external consultant
has a adopted a thorough and comprehensive
whole of agency approach for the review, which
also involves the assessment of suitable cell
accommodation for inmates deemed to be at risk.
Active consultation with Justice Health and allied
mental health professional has also been required
for this review.
Upon completion, the final report of the Review and
its recommendations will be subject to consideration
by the Commissioner of CSNSW.
36
2. That the Department of Corrective (2) An independent expert review as commissioned
Services review its Investigative Services by CSNSW which examined the investigative
Branch and the requirements of reports structure within CSNSW and the respective roles
made by its investigators to ensure that performed by each unit.
full information is gathered, systemic
issues are identified and if necessary any The independent expert review was conducted by
recommendations are made, by the Mal Brammer, a former Executive Director with the
Investigators both for the use of the Independent Commission Against Corruption (and
Coroner and for full consideration by the former Assistant Commissioner, NSW Police
Department. Force).
In accordance with the coronial recommendation,
part of the Brammer review addressed the response
and reporting of deaths in custody by CSNSW
Investigations, including that report writing identifies
any systemic issues or concerns and that any
recommendations are fully considered by CSNSW.
The independent review by Brammer was
completed and the review’s recommendations on
the functions and procedures of CSNSW
Investigations were fully implemented and
operational by CSNSW.
A new management structure and greater
accountability measures have been implemented
which have led to significant organisational and
procedural changes to CSNSW investigations.
This has included the appointment of David Byrne
as General Manager of CSNSW Investigations on
14 September 2009. David is a former Detective
Sergeant with the NSW Police Force and has over
21 years experience in the field of criminal
investigation.
Reports from CSNSW Investigations into death in
custody are prepared and submitted to the
CSNXSW Board of Management ‘Management of
Deaths in Custody Committee’ within 60 days.
37
The reports contain recommendations made by
CSNSW Investigations where required. Those
recommendations are not limited on subject matter
and will identify and comment on any identified
issues including but not limited to systemic matters.
This process has been further enhanced by the
creation and commencement of the CSNSW Board
of Management ‘Management of Deaths in Custody
Committee’ – first meeting held in December 2009 –
which actively considers the implementation of
recommendations arising from CSNSW
Investigations reports and Coronial inquests.
The 14- member Committee meets months and is
strategically comprised of senior executives from
Justice Health and CSNSW. This ensures that the
most appropriate and timely action is taken in
response to reports (including CSNSW
Investigations reports and Coronial inquests) and
implementation of any recommendations arising
from investigations of these critical incidents. A
representative from the NSW State Coroner’s Court
also attends meeting as an invited observer on the
Committee.
3. That the Department of Corrective
Services provide all investigation reports 3) This recommendation has been fully
undertaken by or on behalf of the said implemented, where Corrective Services NSW’s
Department into deaths in custody to the procedures and practices adhere to this
Office of the State Coroner immediately requirement.
upon finalisation (subject to any legal
claims made).
FUTURE – Next All three recommendations made by the Coroner in this matter have been fully implemented by NSW Corrective Services and are operational.
response
38
TOP
Name of
Date, Recommendations
Deceased & Finding Recommendations Response
Venue & Coroner made to:
File No.
SUPPRESSED Deputy State I find that the Australian Medical I recommend that the Australian Medical Association Not Government agencies,
#3 Coroner deceased died on Association and the Royal Australian College of General so no required to notify
1020/07 MacPherson the 14th June from Practitioners include mandatory training of suicide Attorney General of
a gunshot wound to Royal Australian prevention and crisis management in the regular training response.
Non publication 6 April 2010 the head self- College of General of medical practitioners should so that they can
order under inflicted with the Practitioners effectively and compassionately treat patients
section 75 At Glebe intention of taking experiencing suicidality. And that this training should be
Coroner’s Act his own life. (18/05/2010) a regular part of general practice professional
2009 development and accredited by an independent body.
Commissioner of Detective Inspector Michael John Heap has been of 17 August 2010, the
Police tremendous assistance particularly organising the Commissioner of Police
experiment with the subject firearm and with the advised that the Deputy State
preparation of an extensive and professional brief of Coroner’s recommendation
evidence and I intend to acknowledge that in a had been noted and brought
recommendation of a commendation to his superiors. to the attention of the
Northern Region
Commander.
FUTURE – Next
response
39
TOP
Name of Date, Finding Recommendations Recommendations Response
Deceased Venue and made to
and File No Coroner
Paul Hogan State That Paul Hogan Justice Health 1. When an inmate has a history of Minister for Health September 2010:
1435/08 Coroner died on 26 August serious mental ill-health, e.g.
Jerram 2008 at Goulburn depression, Justice Health place an An Inmate Health Survey was undertaken by JH in
Correctional Centre alert on the PAS, that will be obvious 2009. The survey established the three (3) most
7 June by hanging by to staff accessing the system. common mental health conditions in this population as
2010 himself with the 2. That Justice Health provide depression, anxiety and drug dependence. The results
intention of ending mandatory annual training courses for showed that 43% of the respondents declared they had
his own life nursing staff working within NSW been assessed or treated for a mental health problem.
At Correctional Centres (other than These results suggest that if alerts for inmates with a
Goulburn those qualified in mental health) in mental health problem such as depression were placed
the area of suicide risk assessment on the PAS system, alerts would be on the records of a
and mental health first aid very high proportion of the prison population.
Consequently, the following advice was provided in
regard to implementing this recommendation:
Alerts are placed on the PAS for inmates with an
active mental illness but placing an alert as
suggested in this recommendation would dilute the
effectiveness of an alert for inmates whose mental
health is of concern and would not improve the
identification of those inmates at risk of suicide.
There are mechanisms in place for identifying
suicide risk that include cross-agency Risk
Assessment and Intervention Teams, Health
Problem Notification Forms and ongoing clinical
assessments.
JH will continue to use PAS alerts to record serious
mental illness and current risk of suicide and self-
harm.
The NSW Suicide Prevention Strategy 2010-2015, was
launched on September 10 at a community forum
40
organised by Suicide Prevention Australia. This
document presents a whole of government approach to
sharing the responsibility for suicide prevention by
strengthening the capacity for all sections of our
communities to work together.
Additionally:
In-house training sessions are conducted regularly
including courses in assessing the risk of suicide.
A mandatory annual in-service refresher program in
assessing suicide risk is being developed.
Commissioner of 1. When an authorised officer makes a Commissioner of Corrective Services on 2 December
Corrective decision about whether an inmate 2010:
Services should be placed in segregation
pursuant to s. 10 of the Crimes “These findings and recommendations have been
(Administration of Sentences) Act carefully considered by Corrective Services NSW. In
1999, the officer must have regard to accordance with Premier’s Memorandum 2009-12, a
an inmate’s history of mental illness formal response to the coronial recommendations has
by reference to OIMs, case been prepared by Corrective Services NSW…the
management files and discharge coronial recommendations and advice on the
summaries. They should also refer to consideration and action taken to implement the
Justice Health staff to obtain essential recommendations are reported in the attached
information relating to mental and schedule”.
physical health.
2. Wherever practicable, when an The schedule and report can be viewed here.
inmate is placed in segregation a
welfare officer or senior correctional
services officer should meet with the
inmate within 24 hours of the order
being made, so as to determine
immediate welfare needs and to
advise the inmate of their right to
access relevant services and options,
e.g. family visits, library services.
3. Corrective Services NSW should
introduce a mandatory training
programme that must be completed
by all corrections officers as soon as
practicable. Training should include:
41
a. Identifying mental health
needs of inmates.
b. Appropriate responses to
mental health needs of
inmates.
c. First-aid.
d. Standard operating
procedures relating to deaths
in custody.
4. Where an internal investigation is
carried out in relation to a death in
custody, the General Manager of the
Correctional Centre must make
arrangements to ensure all Corrective
Services officers they are responsible
for are familiar with any significant
findings or recommendations made.
(Note: This echoes a
recommendation previously made in
the inquest in to the death of Adam
Shipley.)
5. Corrective Services NSW review the
absence of inmate checks between 3
pm and 8 am and investigate the
feasibility of adopting a procedure
whereby inmates in segregation are
checked at reasonable intervals
during that period.
FUTURE –
Next
response
42
TOP
Name of
Date, Recommendations
Deceased & Finding Recommendations Response
Venue & Coroner made to:
File No.
Jennifer That Jennifer Johnson died at Civil Aviation Safety I recommend that the Civil Aviation Authority Awaited
JOHNSON Deputy State Coroner Camden NSW on 15 August Authority (Federal conduct such investigations as are necessary to
Dillon 2003 of multiple injuries Government agency) determine the reliability of the figure of 1.3 litres
sustained in an air crash shown as the quantity of unusable fuel for Victa
26 February 2010 following a fuel starvation event, Airtourer aircraft in that aircraft’s approved flight
the cause of which is uncertain. manual.
I recommend that the Civil Aviation Authority
require such changes to the content of the flight
manual for the Victa Airtourer as may be required
by the outcome of those investigations.
FUTURE –
Next
response
43
TOP
Name of
Date, Recommendations
Deceased & Finding Recommendations Response
Venue & Coroner made to:
File No.
Peter Deputy State Coroner I find that Peter NSW Maritime 1) I recommend that the NSW Maritime Authority, with the Minister the Hon P
EAGLE Dillon Eagle died on 8 Authority/Minister Australian Power Boat Association and any other person or MacLeay MP on 7 July
March 2008 in for Ports body the Authority may consider appropriate, conduct a 2010:
391/08 27 April 2010 Sydney study by a suitable expert or experts into the safety of crew
Harbour by involved in high-speed crashes of recreational and racing “Officers from NSW
drowning, while power boats with a view to developing practicable Maritime met with the
At Glebe driving power measures at reasonable cost for improved standards of sports governing body, the
boat Reg No safety. Australian Power Boat
N24. Association (APBA) on 19
2) I recommend that, if such study is conducted, particular May 2010 to discuss the
attention is paid to the question of improving the design and recommendations of the
equipment of such vessels to increase the survivability of inquest.”
crews involved in high-speed crashes.
FUTURE – Deputy Coroner Dillon’s recommendations have been adopted by the APBA and NSW Maritime. APBA’s National President tabled the recommendations at its
Next national board meeting on 22 May 2010 for consideration at an Australia-wide level. Other safety recommendations will be presented to APBA’s Board to
response enhance currently safety initiatives and support changes resulting from Deputy Coroner Dillon’s recommendations.
44
TOP
Name of Date, Finding Recommendations Recommendation Response
Deceased & Venue and made to:
File No Coroner
Mary Ruby I find that: Mary Minister for 1. That there be better and Response awaited
FORRESTER Ruby FORRESTER Transport and more personal training [for
978/08 State died at Orange Roads taxi drivers], that is with
Coroner Base Hospital on (28/04/2010) teachers, which is
Jerram 19 June 2006 of a standardised across New
Cardiomegalia due South Wales
23 April to Hypertension
2010 and Ischaemic 2. That the Minister for
Heart Disease, a Transport regulates so that
At Orange condition possibly persons in three wheel
contributing to her scooters, are not to be
death being a taken as passengers in
fractured femur disabled taxis unless
resulting from a fall accompanied by qualified
in a taxicab. staff.
Minister for Health Minister for Health November 2010:
(28/04/2010)
The Greater Western Area Health Service (GWAHS), the
Ambulance Service of NSW (ASNSW) and Department of
Health support the intent of Coroner’s recommendation that
high risk patients be closely supervised and the most
appropriate mode of transport be utilised is supported,
however would not support the use of an ambulance for the
transport of residents unless clinically required. An
appropriate assessment of each individual when determining
their specific transport needs is strongly supported and will
better address that intent and ensure a safer approach to
providing transport for residents who need this assistance.
45
The Department has advised the use of an appropriate tool to
assess the level of risk and needs of people requiring
transport would allow consistent identification of appropriate
transport providers and/or the need for an escort. The
Department advises that NSW Health’s current ‘Transport for
Health’ policy contains a Patient Screening Tool and
Classification Framework Tables which, used together, can
assist in determining suitable transport for persons travelling
to and from health services.
Advice from the Ambulance Service of NSW (ASNSW) is that
the most appropriate mode of transport for each individual
should be in accordance with their clinical needs. ASNSW
advised that the use of ambulance vehicles for non-
emergency transport would have an adverse impact on the
availability of Ambulance resources and its capacity to deliver
emergency services.
FUTURE –
Next
response
46
TOP
Name of
Date, Recommendations
Deceased & Finding Recommendations Response
Venue & Coroner made to:
File No.
Phillip John Deputy State Coroner Elliot That Phillip John Midson Minister for To the National Transport Commission David Campbell MP, Minister for
MIDSON died no 24 July 2009 at Transport and the Roads and Traffic Authority of Transport, 6 April 2010:
5 August 2009 Bulahdelah from head NSW (RTA), that the ‘Load Restraint
injury, subcutaneous Guide’ be amended as to include a “ I am advised by the RTA that
At Raymond Terrace haematoma, cerebellar specific section for ‘Concrete Culverts the Load Restraint Guide is a
and subarachnoid and the Like’, with emphasis on an national publication issued by the
haemorrhage, accidentally assessment being made of the Centre of National Transport Commission
received when the truck Mass, and, if it is higher than the height (NTC). The RTA’s General
he was driving overturned. of the Concrete Culvert, it be transported Manager of Safer Vehicles
only on a low-loader. This incident could (Centre for Road Safety) has
have been avoided had the Concrete written to the NTC providing the
Culverts been inverted. RTA’s assessment of the Guide
and offering any assistance
should the National Transport
Commission decide to amend the
Guide. ”
FUTURE –
Next
response
47
TOP
Name of Date, Venue and Finding Recommendation Recommendation Response
Deceased and file Coroner made to:
number
James Anthony Deputy State I find that Mr James Engert died Minister for 1. I recommend that Sydney The Hon David Campbell MP,
ENGERT Coroner Dillon on 28 March 2007 in Sydney Transport Ferries engage a specialist in Minister for Transport and Roads,
522/07 Harbour off Dawes Point as a (17/03/2010) “Human Factors” and “Safety responded on 4 May 2010 as follows:
On 23 February result of the combined effects of Culture” to review its progress
Alan Arthur BLINN 2010 multiple injuries and drowning in developing a high-reliability, “… All six recommendations are
523/07 occasioned when the ferry Pam safety culture within the accepted. Sydney Ferries has
At Glebe Burridge collided with the cruiser organisation. commenced action to implement
Simone MOORE Merinda. 2. I recommend, if such a review these recommendations…”
524/07 is conducted, that it engage
I find that Dr Alan Blinn died on both management and fleet
Morgan INNES 28 March 2007 in Sydney crews in its considerations.
558/07 Harbour off Dawes Point as a 3. I recommend that Sydney
result of the combined effects of Ferries consider instructing
multiple injuries and drowning masters operating ferries to
occasioned when the ferry Pam use other crew members as
Burridge collided with the cruiser look-outs in the wheelhouse at
Merinda. night and in the transit zone
and other busy parts of the
I find that Ms Simone Moore Harbour unless other more
died on 28 March 2007 in urgent duties require them
Sydney Harbour off Dawes Point elsewhere on the vessel.
as a result of the combined 4. I recommend that NSW
effects of multiple injuries and Maritime and Sydney Ports, in
drowning occasioned when the consultation with relevant
ferry Pam Burridge collided with Harbour users and
the cruiser Merinda. representative bodies, consider
how best to promote the
I find that Ms Morgan Innes died practice of reporting unlit
on 28 March 2007 in Sydney vessels to Harbour Control.
Harbour off Dawes Point as a 5. I recommend that, if it is
result of the combined effects of technologically feasible and
multiple injuries and drowning practicable, radio traffic
48
occasioned when the ferry Pam generated by Sydney Ferries
Burridge collided with the cruiser be recorded and archived for a
Merinda. suitable period.
6. I recommend that Sydney
Ferries consider imposing a
night speed limit on fast ferries
regardless of whether NSW
Maritime imposes such a limit.
Minister for Ports 1. I recommend that Sydney Minister the Hon Paul McLeay MP on
& Waterways Ports and NSW Maritime, in 6 August 2010:
(17/03/2010) consultation with relevant
Harbour users, consider how “I am advised that NSW Maritime
best to promote the practice of undertook extensive consultation
reporting unlit vessels to with various stakeholder groups and
Harbour Control. with the boating industry to
2. I recommend that the investigate the practical issues
Marine Safety legislation and associated with the
regulations be amended so as recommendations.
to require that operators of
registered or registrable NSW Maritime has developed an
recreational vessels – vessels implementation program for eleven
powered by engines with a recommendations. There are four
rating of 4 kilowatts (5 h.p.) or recommendations where NSW
more; power-driven or sailing Maritime has identified practical
vessels 5.5 metres or longer; implementation issues and therefore
and vessels subject to mooring further attention is required.”
licences – be licensed. Note:
the intention of this To view the entire NSW Maritime
recommendation is to cover response, click here.
boats that are capable either of
high speeds or of carrying
significant numbers of
passengers. If there is a better
definition of such vessels, I
recommend that it be pursued
in the alternative to the above
proposal.
3. I recommend that the
requirements for obtaining a
49
NSW boat licence be amended
so as to include
comprehensive practical
training in accordance with
national standards developed
by the National Marine Safety
Committee, involving a number
of lessons, including a night
training session, and
culminating in an appropriate
skills test as well as a
theoretical test by NSW
Maritime.
4. I recommend the inclusion
in the Boating Handbook of a
night lookout checklist.
5. I recommend that NSW
Maritime liaise with other State
maritime authorities through
the National Marine Safety
Committee concerning the
issue of unlit vessels in busy
waterways and request that
they consider a unified national
regulatory approach to the
question whether boats of the
relevant type (that is, boats
which, if navigating at night
would require fixed navigation
lights to be illuminated) ought
be required to have them fitted.
6. I recommend that NSW
Maritime give consideration to
requiring periodic checks of
navigation lights for registered
boats in NSW and to the
optimal method of conducting
such checks.
7. I recommend that NSW
50
Maritime consider making the
current “50 Point safety check”
that it has developed with the
Boating Industry Association
compulsory on a suitable
periodic basis to be
determined.
8. I recommend that NSW
Maritime give consideration to
starting a programme
encouraging the fitting of radar
reflectors and devices warning
crews that navigation lights are
not illuminated at night to
vessels that carry side lights
and mast head lights.
9. I recommend that NSW
Maritime consider providing an
online “complaints” section to
its website to enable boat
operators to report serious
breaches of marine rules and
legislation.
10. I recommend that NSW
Maritime immediately
reconsiders the Code of
Conduct and redrafts such
parts of it that require
clarification. The North/South
Rule is one such part.
11. I recommend that NSW
Maritime give consideration to
the optimal method of
enforcing compliance with the
Code of Conduct and
implements that method.
12. I recommend that, insofar
as it is able to without
diminishing its effort
51
elsewhere, NSW Maritime
increases night-time patrols,
especially during times of
relatively high traffic.
13. I recommend that NSW
Maritime give close
consideration to the best
method(s) of enforcing speed
limits within Sydney Cove.
14. I recommend that NSW
Maritime give further and
closer consideration to the
desirability of imposing speed
limits in Sydney Harbour and
its tributaries such as the
Parramatta River, or in certain
areas of the Harbour and its
tributaries, and during hours of
darkness and restricted
visibility.
15. I recommend that the
Minister commission a
comprehensive risk
assessment of highspeed
vessel operations at night on
Sydney Harbour.
National Marine I recommend that the National
Safety Committee Marine Safety Committee seeks,
(17/03/2010) through the Australian Transport
Council or other appropriate
avenues, to obtain agreement from
State and Territory Maritime
authorities regarding the
implementation of national
minimum standards for recreational
boat licensing, including training
and assessment in accordance
with national principles and
standards already developed.
52
Commissioner of I recommend that, insofar as it is Acknowledgement received
Police practicable to do so without 11/3/2010.
(17/03/2010) diminishing its effort elsewhere, the
NSW Police Force Marine Area The NSW Police Force
Command increases night time acknowledges the suggestion of the
patrols on Sydney Harbour, Deputy State Coroner and can
especially during times of relatively indicate that the Marina Area
high traffic, with a view to detecting Command Sydney Sector is
unlit vessels and enforcing marine responsible for providing a marine
legislation generally. response to Port Jackson and the
coastal area between Long Reef and
Maroubra. At least one police vessel
is available for patrols of this area at
all times. There is continual
monitoring of on-water activity and
associated crime. This permits the
identification of locations where
crime trends and/or safety
compliance issues present
heightened risk to the NSW public.
Marine Area Command patrols are
conducted in the awareness of and
with attention to areas of heightened
risk. A monthly crime report is
generated and all information
reviewed to ensure that all on water
activity is assessed to permit the
most efficient utilisation of available
resources.
Royal Humane I recommend that the Society
Society of New consider conferring an appropriate
South Wales award on Mr Matthew O’Grady and
(17/03/2010) Mr Con Sakoulas for their efforts in
saving lives of survivors of the
Merinda and for their attempts to
save the lives of those who lost
their lives in the collision.
FUTURE – Next
response
53
TOP
Name of Date, Finding Recommendation Recommendation Response
Deceased Venue and made to:
and file Coroner
number
Infant Deputy That eight The Minister 1) That a continuing On 5 September 2010 The Hon Ms Barbara Perry MP, Minister for Local
Swimming State children responsible for media campaign be Government responded as follows:
Pool Coroner (who cannot the developed by the
Deaths MacMahon be named) administration of relevant NSW “1) and 2) The NSW Government currently provides over $2.2 million
died from the Swimming Government and the Commonwealth Government is providing over $38 million over
30 April drowning or Pools Act 1992 Department in four years to June 2010 to key water safety organisations, including the
2010 hypoxic (Minister for conjunction with the Royal Life Saving Society, to provide a broad range of water safety
brain injury Local Royal Life Saving research, projects and education initiatives, including swimming pools.
At Glebe when they Government) Society and other This includes a $20,000 grant to the Royal Life Saving Society to enable
fell into appropriate non- them to distribute the Pool Safety in a Box safety kit to councils and child
swimming Government bodies to care centres.
pools. emphasise the need for
constant supervision of The Division of Local Government, Department of Premier and Cabinet
young children who has arranged the printing and distribution to Councils of the Swimming
are, or reside, in the Pools Law Brochure and the Home Swimming Pool Safety Checklist.
vicinity of a home These brochures and other relevant information are also available on the
swimming pool. Division’s website. The brochures are being translated into community
2) That a media campaign languages which will also be available on the website.
be developed by the
relevant NSW Councils will be asked to deliver a locally based campaign that draws
Government attention to the critical importance of swimming pool barriers meeting the
Department, in requirements of the Swimming Pools Act 1992 and the Swimming Pools
conjunction with local Regulation 2008.
Government authorities
within NSW, to
emphasise the need 3) Similar proposals have been previously considered by the NSW
for: Government. The Government has noted that they are administratively
Obtaining of complex, and have major resource implications for councils. The only
approval of the way they can be implemented is if all associated costs were passed on
54
construction and to pool owners. These proposals are not supported by a cost benefit
installation of all analysis which has been previously completed. It should also be noted
home swimming that many councils would potentially have difficulty employing sufficient
pools whether in or skilled staff to undertake an inspection program.
above ground; and
The need for 4) Amendments to the Swimming Pools Act 1992 commenced on 14
regular December 2009 to strengthen council powers to enforce the
maintenance of requirements of the Act.
fencing and gates
surrounding such Further, from 1 July 2010, newly constructed pools on very small
pools; properties, large properties and waterfront properties will no longer
The need to ensure receive automatic exemptions from the requirement for four-sided, child-
that pool gates are resistant pool barriers. Penalties for non-compliance with the
never propped requirements of the principal Act and Regulation have also been
open. increased significantly.
3) That consideration be given
to the relevant NSW The Government has considered the removal of exemptions for existing
Government Department in pools and has noted that this has major cost implications for existing
conjunction with local exempt pool owners. The average cost of retro fitting fencing to an
government authorities existing pool is estimated to commence at approximately $5,000. These
within NSW, costs could be as high as $10,000 or more in some sites and has not
Developing a been supported by the cost/benefit analysis previously completed.
centralised register of
private swimming However, the Minister for Local Government is prepared to consider the
pools; and Coroner’s recommendations further. The Minister has written to the
Developing a relevant Ministers, including the Minister for Fair Trading, the Minister for
systematic plan for the Sport and Recreation, the Minister for Lands and Planning and the
regular review of all Attorney General, seeking agreement to form a cross agency working
private swimming pools group to further consider all the Coroner’s recommendations and any
in NSW so as to ensure other initiatives to strengthen swimming pool safety.
compliance of such
pools with the safety This working group will be facilitated by the Director, Legal, Policy and
provisions of the Special Programs, Division of Local Government, NSW Premiers and
Swimming Pools Act Cabinet.”
1992.
4) Consideration is to be given 2011 Update
to an amendment of the On 17 May 2011, the Hon Don Page MP, Minister for Local Government,
Swimming Pools Act so as to advised the Attorney General further in relation to the Working Group.
remove all exemptions from the That letter can be viewed here. The Minister advises that the Division of
55
application of that Act. Local Government has been asked to reconvene the Working Party with
a Final Report to be available for consideration by relevant Ministers by
the end of June 2011. The Minister intends for a Minute to be submitted
for Cabinet consideration in July 2011 detailing a co-ordinated
Government response to the issues of private swimming pool safety and
seeking Cabinet approval for strengthened legislation to be introduced
into Parliament in the Spring session of 2011.
The Cross Agency Working Group met on 7 June 2011 and it is
expected that a draft report on the recommendations would be
distributed by Local Government.
To the Minister 1) That consideration be given to Section 52 of the new Residential Tenancies Act 2010, which will
responsible for providing by law that: commence later this year, makes it a term of every residential tenancy
the Owners of residential agreement that a landlord must comply with their statutory obligations
administration of properties that contain relating to the health or safety of the residential premises. The Act
the Residential a private swimming makes specific reference to the landlord’s obligations under the
Tenancies Act pool and are the Swimming Pools Act 1992.
1997 (Minister for subject of a residential
Fair Trading) tenancy agreement are
obliged to take all
reasonable action to
ensure that the pool is
and remains compliant
with the safety
provisions of the
Swimming Pools Act
1992 and
That the owner of a
property containing a
private swimming pool,
that is the subject of a
residential tenancy
agreement, should
warrant at the
commencement of
each such agreement
that the pool and the
surrounding fencing
and gates comply with
56
the safety provisions of
the Swimming Pools
Act 1992.
To the Minister That the relevant NSW Government Advice will be prepared for the Government regarding feasible options
with Department in conjunction with for implementing this recommendation, including threshold issues
responsibility for industry associations develop regarding the types of above ground pools to be covered by any
administering the systems; regulation. The advice will need to be developed in consultation with the
Fair Trading Act To ensure that purchasers Minister for Local Government, owing to the interaction between the Fair
1997 of aboveground pools are Trading Act and the Swimming Pools Act.
advised at the point of sale In addition, in 1998 the New South Wales Products Safety Committee
of their obligations under developed product safety guidelines around the safety of inflatable pools
the Swimming Pools Act which included warning labels to alert pool owners of the potential
1992, and drowning hazard, the need for water purification and the need to store
Sellers advise the relevant pools safely when not in use.
local government authority
of the delivery of an Fair Trading recently updated the guidelines and produced two fact
aboveground swimming sheets to reinforce the water safety message.
pool to a property within the
boundaries of that There has been a very high level of compliance with the guidelines since
authority. their introduction. A product safety campaign over the 2009/2010
Christmas period found an almost 100% compliance rate.
Given the recently agreed national approach to consistent product safety
laws, the Minister for Fair Trading has also approached her
Commonwealth counterpart about making these guidelines mandatory.
Fair Trading will continue its compliance activities in the lead up to
summer.
To the Attorney That consideration be given to the NSW Department of Attorney General and Justice (DAGJ) Criminal Law
General enactment of a criminal offence, Review Division on 23 May 2011:
analogous to that of negligent
driving causing death, to apply in The Department has consulted with key stakeholders on the proposal.
circumstances where a person dies Stakeholders oppose the proposal for various reasons, including:
as a result of the negligence of a • the creation of such an offence would criminalise a broad range of
third party with respect to the acts and omissions that are not currently an offence (including acts
57
maintenance or use of a private or omissions of parents whose momentary inattention results
pool. tragically in the death or serious injury of a child);
• the proposed heavy imprisonment sanctions imposed on parents in
such tragic (and currently non-criminal) situations would be punitive
in the extreme and add very little in the way of general or specific
deterrence;
• that the existing criminal offences are sufficient and appropriate in a
range of circumstances where it is considered that a criminal
standard of negligence has been occasioned.
The Attorney has been briefed on the issues, and the DPP has been
advised that the proposal is not to be progressed at this time.
FUTURE –
Next
response
58
TOP
Name of
Date, Recommendations
Deceased & Finding Recommendation Response
Venue & Coroner made to:
File No.
Peter Gordon Deputy State Coroner That Peter Gordon Commissioner of 1) That the Commissioner has the The NSW Police Force does not believe
WILSON Dillon Wilson died from Police Standard Operating Procedures (SOPs) that a full risk assessment by an
1757/06 the effects of subjected to a full risk assessment by an independent expert or organisation is
multiple injuries independent expert or organisation. required as it is of the view that it has the
5 August 2009 inflicted when he capacity to adequately assess the SOPs
was hit by a motor with external input as required.
vehicle on the F3
Freeway near Since the incident occurred, the SOPs
Somersby. have been subjected to an extensive
assessment and review process with
external agency input. For example, in
January 2007, the Traffic Services Branch
convened a Working Party comprising
representatives from the Safety
Command, Human Resources,
WorkCover NSW and operational police
officers to assess and review the SOPs.
Additionally, the NSW Police Association
has had input into the SOPs. We will
continue to assess and review the SOPs
as necessary with external input as
required.
2) That, when the Police Force conducts This recommendation is supported and
its review of the current SOPs, it reviews of the SOPs will canvass relevant
considers relevant and comparable and comparable practice in other
international practice and gauge them in jurisdictions as required.
the light of best international practice.
59
3) That consideration be given to Currently, the SOPs require Police to
modifying the SOPs so as to prevent make use of police vehicles or stationary
police from working on roadways unless objects as barriers while signalling
protected by police vehicles or other vehicles to stop.
stationary protective barriers placed in
suitable positions by police. For the While this recommendation is supported
purposes of this recommendation, a insofar as it relates to stationary traffic
civilian vehicle temporarily stopped by enforcement, there will inevitably be
police in a traffic lane is not considered a instances of unplanned or emergency
‘stationary protective barrier’ placed in a situations where such conditions could
suitable position. not readily be met.
In all cases, safe practices will be the
issue of prime importance, while
balancing the requirements for the
maintenance of efficient traffic flow.
4) That consideration be given to the This recommendation is supported and is
amendment of SOPs to make clear that addressed in the current SOPs.
as much warning as possible is to be
provided by stopping police to targeted
vehicles by using the warning lights on
their police vehicles once a speeding
vehicle is detected.
5) That the SOPs be amended to This recommendation is supported and is
incorporate an express operating addressed in the current SOPs.
assumption that every time an officer
attempts to stop an oncoming vehicle,
he or she is exposed to a person who
may deliberately, negligently or
accidentally drive at them.
60
6) That all safety procedures referred to This recommendation is supported and is
in the SOPs, including site assessment, addressed in the current SOPs.
escape routes, directions concerning
walking on roadways, use of signals and
so on, be based on the premise in
Recommendation 5 and the exposure of
officers to such drivers be reduced to the
minimum necessary to conduct
operations in accordance with that
premise.
7) That consideration be given to This recommendation is partially
eliminating traffic law enforcement supported. Consistent with point 148 of
operations by police on foot at multi-lane the Deputy Coroner’s findings that
sites. Where the speed limit is 80 kph or consideration be given to prohibiting multi
greater and their replacement with other lane sites with speed limits OVER 80kph,
alternatives such as mobile speed the NSW Police Force agrees that
cameras and vehicle based LIDARS or stationary speed law enforcement
other instruments. operations conducted on foot should not
occur in speed zones greater than 80 kph.
This will permit police to conduct
operations speed zones up to and
including 80kph, thereby taking in account
the extensive number of locations in NSW
with 80 kph limits.
Enforcement related technology and
related equipment are continually
reviewed and examined by the Traffic
Service Branch.
61
8) That consideration be given to This recommendation is supported. The
including within the Highway Patrol Safety Command is working with the
Education Program at Goulburn Police Education and Training Command to
College, training dealing with the role of progress the development of training
‘human factors’ in road accidents and material, which requires further
‘danger experience’ dealing with the evaluation.
police officer’s perception of particular
dangers which arise in stationary speed
enforcement operations. The NSW Police Force can advise that a
Human Factors package has been
developed and incorporated into the
Highway Patrol Education program
9) That consideration be given to
including expanding the Highway Patrol A review of training was conducted.
annual radar assessment to include However, other than the package referred
education of a practical nature to above (8), no opportunities were
reinforcing the importance of ‘human identified to expand training.
factors’ in road accidents and traffic law
enforcement operations to counter any
tendency to over-confidence in ‘danger
perception’.
10) That consideration be given to the The NSW Police Force supports the
creation within the Traffic Services establishment of such a database and
Branch of a database recording consideration is currently being given to
information about sites used for which Command/Business Unit is best
stationary traffic law enforcement placed to develop and maintain the
operations, including details such as database so as to ensure it provides
incidents, accidents and ‘near-misses’ at maximum value.
such sites.
Consideration of the most appropriate
arrangements to implement this
recommendation are continuing.
11) That, if established, the database be This recommendation is supported. Once
used to review and increase the safety established, it is intended that the
of police methodology, for improvement database will inform police methodology,
of training of Highway Patrol Officers training and information dissemination.
and for the dissemination of relevant
information to Highway Patrols in NSW.
62
Minister for 1) That the Roads and Traffic Authority The Fixed Speed Camera Site Selection
Transport and (RTA) consider locating fixed speed Criteria has been developed by the RTA
Roads cameras on freeways and motorways and the NRMA and NSW Police Force.
and other high-speed roads in areas ’Demonstrated speeding problem’ has
(such as the ‘flight deck in Somersby) been identified as a criterion used to
identified by the Police Force as being select sites for fixed speed cameras. In
used regularly by motorists travelling at addition, the difficulty of sites for NSW
dangerous speeds whether or not they Police Force to conduct enforcement is
are also identified as accident ‘black also considered when selecting fixed
spots’. speed camera sites.
In July 2009, the NSW Government
convened the Road Safety Roundtable
2009 involving road safety experts and
stakeholders to investigate practical and
effective ways to reduce the NSW Road
Toll. More effective use of speed camera
technology was a key issue raised at the
Roundtable. The RTA is now examining
ways to use camera technology to reduce
behavioural patterns of speeding and the
road toll.
2) That the RTA investigate placing on RTA will review its website, publications
its website detailed information, and other public information resources to
especially for inexperienced drivers, determine possible changes to inform
about the potential hazards of motorists, particularly inexperienced
approaching police traffic operation sites drivers, about the potential hazards of
and motorists’ responsibilities when approaching police traffic operations sites
doing so. and motorists responsibilities when doing
so.
FUTURE – Next
response
63
TOP
Name of Date, Venue Finding Recommendations Recommendations Response
Deceased and Coroner to
Manoa Deputy State Manoa Tupou died on 28 Commissioner of 1) That Departmental Policies and Minister for Corrective Services on 30
TUPOU Coroner November 2007 at the Corrective Services Procedures be reviewed so as to ensure March 2010:
2172/07 MacMahon Metropolitan Remand and that cells occupied by inmates identified
Reception Centre, as being at risk of self-harm or suicide 1) A statewide audit of correctional
4 September Silverwater Correctional are audited on a regular basis for centres and court cell complexes is
2009 Centre. The cause of his obvious hanging points and where such currently being undertaken by Corrective
death was hanging and the hanging point are identified they are Services NSW.
manner of his death was eliminated.
suicide. The statewide audit requires the
2) That Departmental Policies and identification of obvious hanging points
Procedures be revised to provide that within accommodation cells used for
where an inmate is placed on an housing those inmates identified as being
observation regime, due to their risk of at risk of self-harm or suicide.
suicide or self-harm, the time and other
details of such observations be recorded An update on the actions taken by
in an auditable fashion by the officer/s Corrective Services NSW as a result of
undertaking such observations. the statewide audit will be advised upon
finalisation of the matter.
2) The policies and procedures of
Corrective Services NSW are currently
undergoing revision. This matter has
involved consultation with key
stakeholders. Corrective Services NSW
are currently exploring a variety of options
to address the need to record, in an
auditable fashion, the relevant details for
checks on inmates placed on an
observation regime due to their risk of
suicide or self-harm.
An update on the actions taken by
64
Corrective Services NSW as a result of
the policy and procedural review will be
advised upon finalisation of this matter.
3) That the educational programs
provided for Corrective Services officers 3) A review of the educational programs
by the Department emphasise the duty of delivered to correctional officers was
care that the Department, and its conducted by the Corrective Services
officers, have towards inmates who are Academy in order to assess the level of
assessed as being at risk of self harm or education provided in the subjects of duty
suicide. of care and suicide awareness.
The review concluded that extensive
training is delivered in relation to duty of
care and suicide awareness and
immediate intervention. In addition, the
completion of several assessments is
required by officers towards ensuring
subject competencies are met in these
important areas.
FUTURE – Next Recommendation #2 has been implemented by Corrective Services NSW. In consultation with key stakeholders, Corrective Services NSW completed a
response review of policies and procedures for recording, in an auditable fashion, the relevant details for checks on inmates placed on an observation regime due to
their risk of suicide or self harm. As a result of this review, new procedures for recording observations of inmates under Immediate Support Plans or RIT
Management Plans were implemented and promulgated on 23 August 2010 by Corrective Services NSW. The new procedures require the recording of
details of observation regimes for inmates at risk of suicide or self harm – as well as implementing systems for the storage and retrieval of those records.
65
TOP
Name of Date,
Recommendations
Deceased & Venue & Finding Recommendations Response
made to:
File No. Coroner
Desmond Gielen Deputy That Desmond Walmsley Commissioner of (1)That cells occupied by On 30 March 2010 the Hon Phillip Costa MP, former
WALMSLEY State died on or about 28 Corrective Services inmates identified as being at Minister for Corrective Services advised the Attorney
Coroner September 2007 at the risk of self harm or suicide be General:
MacMahon Long Bay Correctional audited for obvious hanging
Centre. The cause of his points before occupation and
death was hanging and the where such hanging points (1) A Statewide audit of correctional facilities and court
manner of death suicice. are identified they be cell complexes is currently being undertaken by
eliminated. Corrective Services NSW. This audit requires the
identification of obvious hanging points within
accommodation cells used for housing those inmates
identified as being at risk of self harm or suicide.
An update on the actions taken by Corrective Services
NSW as a result of the audit will be advised upon
finalisation of the matter.
(2) That a review of the
systems and protocols of (2) An expert review is currently being conducted by
Corrective Services NSW be the Acting Principal Advisor (Psychology) within
undertaken to ensure that Corrective Services NSW. The Review is nearing
they provide for a co- completion and has adopted a very broad and
ordinated and proactive comprehensive whole-of-agency approach. The final
management plan for inmates report of the Review and its recommendations will be
identified as being at risk of subject to consideration by the Commissioner of
self harm of suicide, Corrective Services.
particularly following the
release or discharge of such
inmates from a RIT protocol.
66
(3) That a review of the 3) A policy review is currently being conducted by
policies of Corrective Corrective Services NSW towards reviewing the
Services NSW be undertaken procedures and response protocols for managing the
to ensure that such policies physical evidence relating to an inmate’s death in
require the preservation of all custody.
relevant physical evidence
relating to the deaths of all In addition, a training package is being developed for
inmates of NSW Correctional non-custodial staff on crime scene preservation and
facilities. continuity of evidence based on existing training which
is delivered to custodial officers.
The final report of the policy and training reviews and
their outcomes will be subject to consideration by the
Commissioner of Corrective Services NSW.
An update on the actions taken by Corrective Services
NSW as a result of these reviews will be advised upon
finalisation of these matters.
67
FUTURE – Next Recommendation #2
response A Complete review has been undertaken by two officers from CSNSW of the organisation’s approach to managing inmates at risk of self harm and suicide.
This review also took into consideration all recent coronial recommendations relating to procedures and policies associated with risk intervention. This review
generated a detailed discussion paper which included a number of options for consideration by CSNSW.
An expert review has now been commission by CSNSW following on from the preliminary review. This will comprehensively examine the risk assessment
protocols and management procedures for those inmates known to be at risk of self harm or suicide. The expert was formerly employed with CSNSW as the
Executive Director, Offender Services and Programs. The external consultant has a adopted a thorough and comprehensive whole-of-agency approach for
the review, which also involves the assessment of suitable cell accommodation for inmates deemed to be at risk. Active consultation with Justice Health and
allied mental health professional has also been required for this review.
Upon completion, the final report of the review and its recommendations will be subject to consideration by the Commissioner of CSNSW. An update of the
action (s) taken by CSNSW as a result of the procedural review will be advised upon finalisation of this matter.
Recommendations # 3
In consultation with key stakeholders, CSNSW reviewed the procedures and response protocols for managing physical evidence relating to an inmate’s death
in custody. As a result of this review, policy documents on serious incident reporting and crime scene management were updated. To give further effect to the
Coroner’s recommendation, these changes were implemented and promulgated on 21 July 2011 in Section 13.8 “Crime Scene Management Policy” of the
CSNSW Offender Policy Manual.
This new policy incorporates and expands upon the crime scene management information previously contained in a range of policies that concern serious
incident response. The new policy applies to crime scenes or potential crime scenes and includes, inter alia, specific information concerning the definition of
what constitutes ‘evidence’, what needs to be secured or preserved as part of the crime scene and the maintenance of the chain of evidence. The new policy
also includes specific information on the maintenance and format of a Crime Scene Time Log; the duties of the First Responding Officer to a serious incident
with regard to the management of the crime scene, through to the management of witnesses, both staff and inmates, and the inclusion of a checklist/
summary of procedures at the end of the policy.
These policy changes have been circulated to all CSNSW staff by way of Deputy Commissioner’s (Offender Management and Operations) Memorandum
dated 21 July 2011.
68
TOP
Name of Date,
Recommendations
Deceased & Venue & Finding Recommendation Response
made to:
File No. Coroner
Alisha JAMAL Deputy State That Alisha NSW Minister for 1) That NSW Health give close Minister for Health September 2010:
(aka RAZA) Coroner Dillon JAMAL died at Health consideration to implementing
the Royal the hypoglycaemia protocol The recommendations have in principle support, however
1996/06 23 March 2010 Prince Alfred developed by the RPAH system wide implementation will require further investigation &
Hospital,
Camperdown,
Newborn Care Department in consultation with appropriate professional groups such as the
At Glebe NSW on 24 all NSW Hospitals at which NSW Pregnancy & Newborn Service Network (PSN) to
December babies are delivered. determine if the intended outcome is achievable
2006 as a
result of bowel RPAH is updating its hypoglycaemia protocol. All Neonatal
atresia and its Intensive Care Units (NICUs) & Special Care Nurseries (SCNs)
complications. within the NSW public health sector have hypoglycaemic
policies in place.
2) That NSW give close NSW Health supports the investigation of existing programs &
consideration to implementing notes the implementation of any state wide education program
or encouraging the adoption of will have financial implications. Consultation with all NSW public
the SCORPIO program, or a hospital maternity units and other key stakeholders (such as the
suitably modified version of it, Australian College of Midwives, Paediatricians and the Rural
or of an equivalent program, in Doctors Association) to identify education programs for
all NSW hospitals at which maintaining clinical competence is to be undertaken by the
babies are delivered, or in all Pregnancy and Newborn Service Network (PSN).
Area Health Services,
whichever is more appropriate.
3) That NSW Health encourage The BTF program might be a suitable implementation vehicle for
the adoption of standardised any standardised assessment charts & to enhance the use of
recording of assessments of the 0-28 days observation charts for all Special Care Nurseries
newborns based on the RPAH that are to be launched later this year. PSN will take this matter
model or some suitable to the next Neonatal Intensive Care Managers Group meeting &
alternative. the High-Risk Obstetric Advisory Group & seek their advice.
69
4) That the Royal Prince Alfred A new roster will be developed to facilitate the rotation of
Hospital give close midwives between the Ante- & Post-natal wards. This roster will
consideration to the prevention ensure that all midwives have a scheduled exposure to post-
of deskilling of midwives by natal patients, as well as broaden their skill & knowledge base
broadening their professional on newborn care. The rotation will occur for 1 week every 6
development by rotation months.
through ante-natal and post-
natal wards or other suitable An education in-service on the care of neonates will be provided
methods. annually to all midwives.
The Department supports the rotation of midwives through
every clinical area of the maternity service in which they work as
a sound management practice to maintain skills in all practice
domains as per the Australian Nursing & Midwifery Council
National Competency Standards for Midwives & to improve both
the skill level & flexibility of the midwifery workforce.
From 1.7.2010 the National Registration and Accreditation
Scheme for Health Professionals requires evidence of
maintenance of clinical competence & skills to be provided in
support of continuing registration.
5) That NSW Health adopt a The PSN would be ideally placed to progress the State-wide
standard procedure for development of a standardised procedure.
describing and recording
vomiting or regurgitation in
newborns in terms of colour,
volume and timing rather than
ambiguous terms such as
‘possets’.
70
6) That, in conjunction with The PSN would be ideally placed to progress the State-wide
recommendations 2 and 5, development of a standardised procedure
NSW Health adopt a standard
colour chart for describing
vomits or regurgitations in
newborns and that it encourage
Area Health Services to install
wall charts or provide other
form(s) of easy reference to the
standard colour chart (such as
cards) in post-natal wards.
Such charts ought carry clear
advice that yellow
regurgitations can indicate
bilious vomiting.
7) That, within the scope of its In December 2010 RPAH implemented a new system of after-
available resources, the Royal hours rostering that has substituted some medical cover with
Prince Alfred Hospital of Area skilled Nurse Practitioners (NP). NPs operate within approved
Health Service, whichever is clinical guidelines & have a wide range of experience, skills &
more appropriate, give close knowledge in their chosen speciality & are able to provide a
consideration to developing a more consistent level of clinical cover than previous
roster within the Newborn Care arrangements with short term seconded medical staff.
Department that would ensure
that a senior Paediatric In response to Recommendation 45 of the Garling Report
Registrar, Fellow or Consultant regarding clinical supervision, the Supervision for Safety Woking
is available on–site at all times. Group (comprising key professional & industrial representatives)
has met twice, confirmed relevant Best Practice principles &
developed high level implementation strategies from patient,
junior clinician, supervisor, team & organisational perspectives.
8) That the Royal Prince Alfred The RPAH Post-natal Policy has been revised to identify the
Hospital develop a protocol required management of newborns who do not pass meconium
concerning the management of within 24 hours of birth. Review of babies who do not pass
newborns who do not pass meconium within the first 24 hours of birth is currently standard
meconium within 24 hours of practice at RPAH.
birth.
71
9) That the Royal Prince Alfred The RPAH Nursing Care Plan for Post-natal Women will be
Hospital develop a protocol or revised to ensure it clearly identifies that a midwife must ask the
checklist for the taking of mother if they have any concerns relating to their newborn. The
observations and assessment Care Plan has been set up to provide a daily guide to midwives
of babies by midwives or & as a result, the outlined practices are performed on a daily
nursing that would specifically basis.
include a practice of asking
mothers whether they have any Note that asking women as to concerns about their baby is
concerns about their babies standard clinical practice & core business of all RPAH Women’s
and the recording of any & Babies service midwives, residents & consultant staff.
concerns expressed.
The Dept of Heath is implementing the ‘Essentials of Care’
program across NSW. The program engages nursing, midwifery
& other clinicians with a focus on improving the experience of
the patient in the hospital setting & achieving cultural change in
the workplace. Staff are encouraged to consider care from a
patient perspective, & to focus on activities which improve the
patient experience. It is envisaged that this program will
increase the skills of nurses & midwives to recognise & respond
to the needs of patients. Whilst the practice of asking mothers
whether they have concerns about their babies could be
included in a protocol or checklist, it is more important that these
skills are embedded in the midwife's holistic approach to their
practice, so that knowledge is applied to every patient
interaction.
The Paediatric BTF program, a further patient safety initiative
includes 6 age-specific paediatric observation charts developed
to assist in the recognition of a deteriorating child. An education
package has been developed & funding provided to Health
Services to support clinical education.
10) I recommend that if such a Reference to is made to the responses to recommendations 5
protocol is developed, or if a and 6.
current protocol is devised, that
is also include a practice of
recording of any vomiting or
regurgitations in terms of
colour, volume and timing (as
per recommendations 5 and 6).
72
FUTURE – Next
response
73
