System failed inmate

The inmate, who cannot be named, hanged himself at Long Bay Correctional Centre in 2007  10 days after he was discharged from an acute care crisis unit, and despite warnings from family to Department of Corrective Services staff that he was about to do so.

The inquest heard despite being classified as "high chronic risk" of suicide, he had not been seen by a psychologist after being placed within the general prison population.

The inquest was told that a transitional care unit for at-risk inmates had been shut and only two of the six psychologist positions at Long Bay were filled at the time of the inmate's death.

In handing down his findings, Deputy State Coroner Paul MacMahon said the department had demonstrated a "failure to adequately staff the psychologist positions it had considered were appropriate", which could have contributed to the inmate's suicide.

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