Deputy State Coroner Derek Lee delivered his findings on Wednesday following an inquest into the death of Alexander Gavranic, who had been held at Junee for more than 18 months.
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," Judge Lee said.
The inquest heard over three days in September that two mental health nurses were responsible for approximately 700 inmates at the jail, with about 400 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, describing Gavranic's wait of more than 300 days as "a fairly typical presentation for a semi-urgent consult".
Judge Lee said Gavranic and others used several pathways to seek mental health support, including a phone call his mother made to the prison expressing 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," he said.
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. "There's no direct factual evidence of any steps taken," Judge Lee said. It does not appear that repeated requests were recognised, the coroner found.
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