Call for custody, hospital changes after Deniliquin man's drug death

Joshua Steven Kerr, 32, died at Port Phillip Prison on August 10, 2022.

He was awaiting trial for offences including aggravated carjacking and had been taken into custody on May 29 the previous year.

Mr Kerr, who was a Yorta Yorta and Gunaikurnai man, had started using drugs at an early age and had served multiple prison terms in both NSW and Victoria.

At the time of his death, he was a regular ice user.

Mr Kerr had been on a prison escort to attend his uncle's funeral in Echuca in the week before his death.

He had to undertake quarantine due to the pandemic upon his return to Port Phillip Prison.

Mr Kerr lit a fire in his cell about 9.15am on the day of his death.

He appeared to have placed a metal strip from a face mask into a powerpoint, burning his mattress.

Tactical operations group officers were called and negotiated with him.

He was removed from his cell and received medical treatment for burns and a psychiatric assessment.

The 32-year-old said he had taken ice, which he had obtained from within the jail.

An ambulance was called and he was taken to St Vincent's Hospital, where he became aggressive in the afternoon.

He demanded to be returned to Port Phillip and left the emergency department without being formally discharged and without the treating doctor's knowledge.

He was placed in a holding cell for about 17 minutes while transport was arranged, then spent 25 minutes in the back of a transport truck before being driven back to the jail, arriving at 4.43pm.

He refused to have his vital signs taken and refused a COVID test, with his cell door closed about 5pm.

The door wasn't to be opened unless tactical operations group staff were present due to his behaviour and he was observed every half hour by corrections and medical staff.

Mr Kerr's actions became increasingly bizarre, which included removing a bandage and stripping off his clothes.

Tactical officers attempted to engage with him to administer medical treatment which could not be done due to his behaviour.

His movements became slower by 7.40pm and he struggled to stand.

Observations were made amid concerns his movements were less pronounced.

Attempts to rouse him were unsuccessful and a code black was called at 8.10pm.

Tactical officers were required and arrived eight minutes later, removed Mr Kerr, and performed CPR.

He was pronounced dead at 8.41pm.

Coroner David Ryan noted it had taken 16 minutes from the point Mr Kerr became unresponsive to him receiving medical treatment.

He said his death could have been prevented if his acute behavioural disturbance had been recognised and properly treated during the day.

Mr Ryan was satisfied the late man would likely have survived if he remained in hospital, and said Mr Kerr should have been taken back to hospital when his behaviour became more erratic in the afternoon.

The coroner made seven recommendations to G4S Custodial Services, which runs the jail, and the St Vincent's Custodial Health Service.

Coroner Ryan recommended staff receive training to recognise and manage drug affected inmates, including those with acute behavioural disturbances, and that hospital staff receive training about acute poisoning management guidelines.

It was also recommended hospital staff receive training to reinforce their authority and responsibility to advocate for the treatment of prisoners in their care and that G4S tactical officers receive training about the importance of consulting medical staff before cancelling a medical escort.

Other recommendations concerned training for staff from the prison and hospital to better understand each other's roles, and G4S training about the circumstances in which they can exercise individual discretion to allow medical staff to enter jail cells.