Prison staff response to a suspected opioid overdose at the Alexander Maconochie Centre was “below optimal”, given the life-threatening nature of the incident, according to a review by the ACT’s independent Custodial Inspector, Rebecca Minty.

The review found a contributing factor to response time was the low staffing on night shift, which resulted in no staff being present in the closest officer station at the time of the incident.

Further, with only one officer in the master control room (MCR), the “utmost urgency of the situation did not appear to be well understood and conveyed to responding officers”. The review made recommendations about the need for adequate staffing levels, as well as ensuring MCR is sufficiently staffed with appropriately experienced officers.

The inspector says: “In a significant failure to comply with incident reporting policies, the incident was not reported to ACT Corrective Services (ACTCS) senior management or the Inspector at the time it occurred.

“On being informed of the incident ACTCS undertook a comprehensive internal review that considered the incident response and reporting and made three recommendations. The Inspector nevertheless conducted her own review noting the value of an independent, public report of the serious matter of a suspected drug overdose in custody.

“It is fortunate that the female detained person was treated quickly once Justice Health staff arrived and she made what appears to be a full recovery. The detained person was also greatly assisted by other female detained people, who administered CPR and made persistent efforts to alert authorities before help arrived.

“The infiltration of drugs into custodial settings has been widely documented. In addition to reducing supply of and demand for drugs, harm minimisation must be an essential part of a prison’s drug strategy. In the case of opioid overdose, the availability of Naloxone, a drug that reverses the effect of opioid overdose is crucial.

“The AMC has Naloxone available for use by Justice Health nurses, and custodial officers after hours when there are no medical services onsite. This is excellent practice”.

Among its eight recommendations, the review urged ACTCS to consider providing detained people with direct access to Naloxone in accommodation units, as well as basic first aid training.

“Detained people may unfortunately be in the situation of being ‘first responders’ to suspected overdoses within units and cells after hours,” Inspector Minty said. “Providing detained people with direct access to Naloxone has the potential to save lives”.

She said the review focused on the response to the incident and did not consider how the drug or drugs that caused the likely overdose were in the possession of the detained person.

The Inspector is also undertaking a comprehensive Healthy Centre Review of the AMC as a whole, with drug supply, demand and harm minimisation a spotlight topic for that review.

The ACT Custodial Inspector provides independent oversight of ACT correctional and youth detention facilities in the ACT and has the discretion to review certain “critical incidents” which occur in these places.