Inmate died after waiting 305 days for help, NSW coroner finds

In short:

A coronial inquest has found a NSW prison inmate waited almost a year for mental health treatment that never came.

The inquest heard there were two mental health nurses responsible for about 700 inmates at the prison.

What's next?

The coroner has recommended staff be instructed on the importance of thorough documentation to ensure urgent requests can be escalated.

A 305-day wait for mental health support likely contributed to the death of an inmate in his cell in a New South Wales prison, a coroner has found.

Alexander Gavranic arrived at Junee Correctional Centre on June 22, 2021, and requested a mental health screening during his initial examination.

He was placed on a waitlist to see a mental health nurse in April 2022, but took his own life in his cell on February 5, 2023, without having received an assessment.

"The wait of at least 305 days … likely caused distress and deterioration of Alex's wellbeing," Deputy State Coroner Derek Lee said in findings delivered on Wednesday.

Over three days in September the court heard there were two mental health nurses responsible for approximately 700 inmates at the jail.

About 400 inmates were on a waitlist for mental health treatment.

Bernadette Barton, one of the nurses employed at Junee while Gavranic was incarcerated, told the inquest she and her colleague were unable to see everybody who needed help.

"We barely scratched the surface," she said.

Ms Barton told the inquest Gravanic's wait of more than 300 days was "a fairly typical presentation for a semi-urgent consult".

Repeated requests not 'recognised'

Judge Lee said Gavranic and others used several pathways to seek mental health support on his behalf.

They included a phone call his mother made to the prison expressing her concern for his mental health in the week leading up to his death.

"Regrettably, none of these pathways actually resulted in Alex being seen by a mental health professional," Judge Lee said.

"There's no direct factual evidence of any steps taken."

Gavranic kept notes about conversations he had with prison officers about needing mental health help.

But the coroner found corresponding records for all entries could not be found in the prison's notes system.

"It doesn’t appear that repeated requests made by Alex were recognised," Judge Lee said.

He recommended Justice, Health and Corrective Services staff be trained to better document inmate requests for mental health assistance.

Judge Lee recommended guidance or instructions be given to prison officers about "the need to thoroughly document any request made directly by an inmate for assistance with accessing mental healthcare services".

"This is so that if the request is not actioned in a timely manner, escalation can occur," he said.

Insufficient resourcing

At the time of Gavranic's death, the prison was privately run by the GEO Group. It is now under the control of Corrective Services NSW.

The court was told staffing levels had remained the same since the transition.

Prison governor Troy Seychelles told the inquest funding would not be increased, despite the continued rise of the jail's population.

Judge Lee said the evidence showed a system in crisis that was "insufficient to meet demand" in Junee.

"I recommend the findings of this inquest be used to advance the position before any future funding or budgetary allocation process that the staffing profile of mental health care services be increased," he said.