Nicholas Rowley

1. 1. lack of verbal consultation between medical practitioner and custody sergeant regarding observation levels

   “That consideration be given to issuing guidance that whenever a detainee is attended upon by a medical practitioner there should be a verbal consultation between the medical practitioner and custody sergeant as to any issues of concern and the level of observations to be had for that detainee in addition to the medical practitioner making detailed notes on the detainee's custody medical record.”

2. 2. lack of joint training for medical practitioners, custody sergeants and assistants

   “That consideration be given to the provision of joint training exercises for medical practitioners, custody sargeants and custody”

3. 3. inadequate training on correct observation levels

   “That training should provide targeted emphasis on the correct levels of observation.”

4. 4. ambiguous instruction to continue observations at current level

   “That consideration should be given to eliminating the phrase 'continue observations at the current level' and require that doctors and custody sargeants specify the level of observation precisely.”

5. 5. lack of training on drug and alcohol risks including methadone intoxication and alcohol withdrawal

   “That training should include targeted training on the risks and dangers of drug and alcohol abuse, including methadone intoxication and alcohol withdrawal, particularly if the detainee is likely to be in custody for upwards of 24 hours.”

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