Deceased
Jasmynd Gibbs
Demographics
33y, male
Coroner
Decision ofDeputy State Coroner Grahame
Date of death
2021-05-07
Finding date
2024-02-20
Cause of death
Complications of methylamphetamine use
AI-generated summary
Jasmynd Gibbs, a 33-year-old First Nations man, died from complications of methylamphetamine use while on supervised parole in May 2021, less than two months after release. He had complex needs including mental health disorders, cognitive disability, childhood trauma, and substance use issues. Despite a supportive mother initially, Jazzy relocated to unsuitable motel accommodation where he had previously relapsed. Community Corrections and support services were fragmented and under-resourced. After disclosing drug use and missing appointments, contact was sporadic. He experienced a fatal ice binge while living in isolation without coordinated mental health or addiction treatment. The coroner found the death resulted from systemic failures—inadequate wrap-around support, insufficient housing options, poor inter-agency communication, and lack of specialised case management. The individual officers acted reasonably within constraints, but the system failed to provide comprehensive integrated care for his complex trauma-informed needs.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
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CORONERS COURT OF NEW SOUTH WALES Inquest: Inquest into the death of Jasmynd Gibbs Hearing dates: 6-7 September 2023, 16 November 2023, 24 November 2023 (Family Statement) Date of findings: 20 February 2024 Place of findings: NSW Coroners Court Lidcombe NSW Findings of: Magistrate Harriet Grahame, Deputy State Coroner Catchwords: CORONIAL LAW – death due to complications of methylamphetamine use; death of a person on supervised parole; wrap around support for parolees with complex needs; File Number: 2021/129807 Representation: Ms R Rodger, Counsel Assisting, instructed by Ms S Crellin (Crown Solicitor’s Office) Ms D White for the Commissioner of Corrective Services New South Wales, instructed by Department of Communities and Justice Ms E Phelan for , instructed by Dowson Turco Lawyers
Non publication orders: Non-publication orders prohibiting publication of certain evidence pursuant to section 74(1)(b) of the Coroners Act 2009 have been made in this Inquest. A copy of these orders, including corresponding orders pursuant to section 65(4) of the Act, can be found on the Registry file.
Findings Identity The person who died is Jasmynd Gibbs.
Date of death Jasmynd Gibbs died on 7 May 2021.
Place of death Jasmynd Gibbs died at John Hunter Hospital, Newcastle.
Cause of death Jasmynd Gibbs died of complications of methylamphetamine use.
Manner of death His death occurred in circumstances of a drug relapse whilst on supervised parole. Jazzy had complex needs and required comprehensive “wrap-around” support which was not available.
Recommendations To the Commissioner of Corrective Services
That the Commissioner of Corrective Services advocate for an increase in both funding and the roll out of wrap-around services for parolees with complex needs including case managers such as those provided by the Community Restorative Centre consistent with the recommendations 99 and 102 of the special Inquiry into the drug ‘Ice”.
That the Commissioner of Corrective Services review training on mental health and complex support needs to identify whether it meets the
needs of Community Corrections Officers.
That the Commissioner of Corrective Services review Community Corrections Policies and Practices to ensure continuity of service to complex support needs parolees by their designated Community Corrections Officer.
That the Commissioner of Corrective Services consider the publication of an information sheet on the role of Corrective Services NSW, the aims of community based supervision and the ways in which non-government organisations can support the management of offenders in the community.
To the Secretary of the Department of Communities and Justice
That the Secretary of the Department of Communities and Justice consider a long term strategy to move away from heavy reliance on motel accommodation for parolees at risk of homelessness, which must involve strategies such as increased funding for Specialist Homelessness Services that can provide wraparound services.
That the Secretary of the Department of Communities and Justice continue the refinement of procedures, as appropriate, requiring annual inspections of Temporary Accommodation providers to ensure ongoing suitability.
That the Secretary of the Department of Communities and Justice continue collaboration with Corrective Services NSW to provide housing assistance for inmates and parolees who are at risk of homelessness, including the development of a Housing Portal on inmate tablets which provides information about
housing services, products and assistance prior to release from custody.
Table of Contents
Introduction
This inquest concerns the death of Jasmynd Ashraf Gibbs. Jasmynd, known as Jazz or Jazzy to his family and friends, was only 33 years of age at the time of his death. He was a proud First Nations man who was loved and supported by his partner and his family. He died on 7 May 2021 at John Hunter Hospital, NSW, slightly less than two months after his release from prison to supervised parole on 18 March 2021. His death was ultimately caused by “complications of methylamphetamine use.”
At the time of his death, Jazzy had complex support needs arising out of a history of childhood trauma, substance abuse, mental illness and a suspected brain injury or cognitive disability. He was living in temporary motel accommodation, was not engaged in counselling or drug and alcohol treatment and had no local medical support.
Jazzy was so much more than the circumstances he struggled with. In her family statement, Jazzy’s mother described him as having a love of music, driving, gardening and sewing. He enjoyed spending time in nature and with his family. He was also fond of attending football games. Jazzy is remembered as “a kind generous soul, a shiny diamond in the rough.”
Jazzy’s mother, step father and partner attended this inquest seeking answers and in the hope that a close examination of the circumstances surrounding Jazzy’s death might shine a light on opportunities to create change for others caught up in the parole system, particularly those struggling with the drug ice. I thank them for their attendance and for their courageous participation in these proceedings. Their heartbreak was palpable as the evidence emerged. I acknowledge their profound pain and grief and respect their commitment to fighting for changes that might assist others.
The role of the coroner and the scope of the inquest
The role of the coroner is to make findings as to the identity of the nominated person and in relation to the place and date of their death. The coroner is also to address issues concerning the manner and cause of the person’s death.1 A coroner may make recommendations, arising from the evidence, in relation to matters that have the capacity to improve public health and safety in the future.2
A list of issues was prepared before the proceedings commenced. These issues guided the investigation and focused on support procedures in place in the lead up to Jazzy’s death. 3 1 Section 81 Coroners Act 2009 (NSW).
2 Section 82 Coroners Act 2009 (NSW).
3 1. Was the management of Mr Gibbs relocation to Raymond Terrace reasonable and appropriate (including with reference to relevant Housing and Community Corrections Policies and Procedures at the time) including: i. Assessment of risks relating to the move; ii. Assessment of prosocial supports relating to the move;
The date, place and medical cause of Jazzy’s death was not in dispute. For this reason the proceedings focussed on the manner or circumstances of Jazzy’s death. The court was keen to understand how a much loved man, on a supervised parole order could end up in such bleak circumstances so soon after his release from custody. Were adequate supports in place? What more could we have done, as a community, to ensure his safety? How many others face similar difficulties on their release from custody? These were the kinds of questions raised by the evidence presented.
The evidence
The court took evidence over four hearing days. The court also received extensive documentary material in seven volumes. This material included witness statements, medical records, various policies and procedures, and the report of an independent expert, Professor Eileen Baldry. Professor Baldry is an Emeritus Professor of Criminology and Law and Justice at the University of NSW. She has over 30 years’ experience in the field of social policy, social development and criminology. Professor Baldry’s research has focused on many issues relevant to this inquest including access to justice, indigenous health and the transition from custody to the community. More specifically, Professor Baldry has done in depth research regarding Indigenous people and mental health disorders and cognitive disabilities and how they are managed by agencies such as community corrections.
The inquest heard oral evidence from nine witnesses who described the support Jazzy was provided after his release from custody and gave insight into aspects of his life in the weeks leading up to his death.
While I am unable to refer specifically to all the available material in detail in my reasons, it has been comprehensively reviewed and assessed. Counsel assisting provided a useful chronological summary in her closing submissions. I rely heavily on that document to set out the uncontroversial material, taking into account the submissions made by the parties where factual disputes or differences of emphasis were raised. All conclusions are my own.
iii. Assessment of appropriateness of residence (including what accommodation was available and how such accommodation is funded); iv. Assessment of the use of electronic monitoring during the period immediately after relocation; v. Arrangement of protective factors prior to move such as GP and psychologist; vi. Engagement with family as to the appropriateness of the move;
The context to Jazzy’s death
It is necessary to place Jazzy’s death in its wider social context prior to examining the particular facts. This court has many times stated that the over-representation of First Nations people in custody is a national disgrace.4 It should be remembered that the overrepresentation of First Nations people is present at every level of the criminal justice system, including in relation to their contact with Community Corrections.5 It appears likely that many of Jazzy’s issues would have been better dealt with outside the criminal justice system, given the inadequate support he received for his mental health, cognitive disability and long term drug and alcohol issues in custody and on periods of prior conditional release.
In trying to unpack what services were actually available to support Jazzy on his supervised release, it was necessary to understand what Community Corrections could offer and what was available through other services offered by entities controlled or funded by the Department of Communities and Justice. Understanding the complex way funding operates for services for people who may be homeless or be at risk of homelessness was no easy task. However, the bewildering structure of support did not hide the basic truth that the sector is grossly underfunded and the consequences of this are devastating. It is an issue to which I will return.
It must also be stressed that Jazzy’s death occurred in the context of his binge use of the drug ice. The Special Commission of Inquiry into crystal methylamphetamine and other amphetamine-type substances (the Ice Inquiry) examined in detail the use and impact of ice and other illicit amphetamine-type substances in NSW as well as examining options to improve the way we respond to the issues raised. In 109 recommendations released in 2020, the Ice Inquiry highlighted the need for very substantial reform across the criminal justice and health systems to tackle the significant social and health harms caused by ice.
Of relevance to these proceedings, The Ice Inquiry called for an urgent increase in government resourcing for drug rehabilitation and treatment, especially in rural, regional and remote NSW. As will become clear, while the government have actioned some of the recommendations, there remains significant work to do. At the time of Jazzy’s death there existed very few treatment options that would suit his complex needs and it seems none were immediately available. It was particularly concerning that workers who gave evidence in this inquest in 2023 indicated they had not yet felt the improvement they had expected following the significant work of the Ice Inquiry6 4 Inquest into the death of Kevin Francis Bugmy (6 July 2022); Inquest into the death of Reuben Button (21 July 2023) among others.
5 Vol 7, Tab 30, Expert report of Professor Eileen Baldry, [9].
6 Kylee Anderson, Transcript, 6 September 2023, p71; Morgan McCarter, Transcript, 7 September 2023, p22.
Professor Baldry drew this court’s attention to a key principle that emerged from the extensive evidence presented to the Ice Inquiry – that is that effective responses must recognise and address the social determinants of ATS use, including trauma7. Dependent use in particular frequently occurs in the context of broad socioeconomic disadvantage and trauma where use is a symptom, rather than the cause of a person’s problems. The Ice Inquiry paid particular attention to the needs of Aboriginal communities where the impact of crystal methylamphetamine is disproportionate because it aggravates the substantial socioeconomic disadvantage and trauma already experienced in those communities. The significant learnings from that inquiry must not be lost.
Professor Baldry stated that “Mr Gibbs’ death from a fatal ICE binge was the final tragic outcome in a persistent cycle over 20 years of serious mental health episodes, AOD use, in and out of prison, attempts to stabilise his MH and abstain from AOD, then further MH episodes and AOD use continuing the cycle. It was not caused by an individual CC officer, an individual housing manager or any other specific individual…It was the result of decades of lack of education, disability, mental health, child protection and other social services provision that Mr Gibbs had a right to.”8 I accept her view and acknowledge her words sum up the relevant context to any investigation of Jazzy’s death.
Background and brief chronology
His mother is a proud Kamilaroi woman who raised both Jazzy and his younger sister after she separated from their father when Jazzy was seven years old. In her family statement she laid bare the inter-generational trauma and disadvantage she and her family have experienced and I thank her for her open and generous interaction with this court.
and her husband participated in these proceedings from the outset, despite her extremely poor health. Her commitment to her son was steadfast and her significant grief at his untimely death was palpable in the court room.
The court was informed that as a young boy Jazzy was sociable and well-liked, he had a good disposition and was very kind. As a young man he was relaxed and sociable and happy to be with his family members, including his grandmother who he lived with in Dubbo for a time. He enjoyed being in nature, gardening and the bush.
7 Vol 7, Tab 30, Expert report of Professor Eileen Baldry, [9].
8 Vol 7, Tab 30, Expert report of Professor Eileen Baldry, [10].
was supervised on parole. Notably, Jazzy’s mental health appeared to deteriorate, and he had re-offended when previously released to parole at both his mother’s home in the Sydney suburb of Burwood and in the Raymond Terrace area where his partner lived.14
I accept counsel assisting’s submission that Jazzy’s most recent period of incarceration arose out of domestic violence offences which are relevant to this inquest only in so far as they resulted in the period on parole which is the focus of the inquest; and that they are relevant to decisions made in relation to the suitability of his accommodation - given that there was an AVO that he not go within 100m of home in Raymond Terrace.15
I note that , who was victim of these offences informed the court that it was her understanding that while incarcerated Jazzy did not use drugs. I note that she remained supportive on his release.
Supervision on Parole by Community Corrections
15 Vol 1, Tab 9, Pre-Sentencing material, p150.
(8) Must have culturally appropriate post release support workers and/or case management services for additional assistance with responsivity and engagement support; (9) Mother will organise psychologist who specialises in Aboriginal issues and refer to local GP for MHCP.16
provided support for Jazzy to attend the local General Practitioner (GP) and the Aboriginal Medical Service (AMS) that knew him and his history well. Records show that expressed concern that the management of Jazzy’s mental health and his abstinence from drugs were the biggest risk factors and that he would be better able to maintain abstinence whilst residing with her rather than returning to Raymond Terrace.17
Jazzy was allocated a Community Corrections Officer (CCO) at Burwood Community Corrections (BCC), David Plowright, and was required to comply with a number of parole conditions which relevantly included conditions to cease drug use and to comply with drug testing.
Five days after Jazzy’s release on 23 March 2021, he telephoned BCC advising that he was too stressed at his mother’s place and that he needed to “go back to the country”. He was advised to find accommodation for the night in the Burwood area, “stay away from mums place if that was a trigger for him” and then attend the BCC office the next day where they could assist him in finding accommodation.18 The Inquest heard evidence from Professor Baldry that it is common for parolees to be released to their parental home and in more than half of those cases the arrangement breaks down shortly after release and the parolee seeks to relocate.19
On the same date records show that BCC considered a post release plan: (1) Consideration be given to EM anklet and twice weekly reporting during period of accommodation instability; (2) Regional NSW as a viable alternative will need advance planning and pre-approval; 16 Vol 1, Tab 9, Pre-Sentencing material, p163-173.
17 Vol 1, Tab 10, OIMS Case Notes, p212.
18 Vol 1, Tab 10, OIMS Case Notes, p219.
19 Professor Eileen Baldry, Transcript, 16 November 2023, p37-38.
(3) Conduct of review into break down of post release plan including liaison with family members.20
The next day, on 24 March 2021, Jazzy spoke to his CCO Mr David Plowright over the phone to discuss a possible move to Dubbo as he felt his current accommodation was too small, that he was not coping with city life but that he was getting on well with his mother.21
On that same day, Mr Plowright telephoned Jazzy’s mother who said that Jazzy was doing very well at home having settled more quickly than on his previous releases from custody, although she reported that he had told her he was having suicidal feelings the day prior.
said that his girlfriend was staying over occasionally, and that she believed Jazzy wanted to move to Dubbo to pursue a relationship with his estranged father.
Mr Plowright indicated that he would discuss those issues with Jazzy when he came in for his scheduled appointment that day. It is clear that was fully committed to open communication with Mr Plowright.
When Jazzy attended later that day he reiterated that he wanted to move to the country as his parents’ place was too small and “he [was] a country boy”. Jazzy stated that Kylee Anderson from the Port Stephens Family Neighbourhood Service (PSFNS) had found him accommodation. Mr Plowright explained to Jazzy that due to his high risk and history of reoffending, a management plan needed to be put in place before he could move and that he would contact Ms Anderson to verify his claims regarding accommodation. Mr Plowright provided Jazzy with a written direction to attend his pre-organised appointment with his family doctor the following day on 26 March 2021 to obtain medication and for the preparation of a Mental Health Care Plan (MHCP).22
Importantly, at this attendance on 25 March 2021, Mr Plowright noted that Jazzy appeared to be suffering from a mental illness and appeared to be emotionally heightened.23 Records note that Jazzy was directed to undertake, and complied with, a drug test which apparently returned a negative result.24
On 26 March 2021, Jazzy attended the GP Dr Sarath Wimalaratne, as arranged by his mother, who provided two referrals: the first was to Concord Repatriation General Hospital 20 Vol 1, Tab 10, OIMS Case Notes, p220.
21 Vol 1, Tab 10, OIMS Case Notes, p220.
22 Vol 1, Tab 10, OIMS Case Notes, p222.
23 Vol 1, Tab 10, OIMS Case Notes, p222.
24 It is not clear whether this test was supervised.
Pain Management Clinic,25 and the second to Dr Duygu Arslan of Welibe Psychology.26 Dr Wimalaratne prepared a Mental Health plan (MHCP) dated 29 March 2019 which noted schizophrenia as the identified issue.27
On 29 and 30 March 2021, Jazzy reported at BCC to see Mr Plowright and he appeared calm and stable. Mr Plowright again indicated that a management plan must be in place and agreed to by his supervisors before Jazzy would be permitted to move. Ms Anderson from PSFNS confirmed her willingness to support the move with Temporary Accommodation (TA) and case management until she had organised long term accommodation.28
On 1 April 2021, Jazzy notified BCC that he had found accommodation from 4 April 2021 at the in Raymond Terrace; accommodation at which he had resided prior to his most recent incarceration. Jazzy said Ms Anderson had helped to arrange the accommodation and he provided a signed letter from the General Manager of confirming rent for the room on a weekly basis.29 Mr Plowright called Ms Anderson the same day to confirm the accommodation as a “permanent weekly rental”.
On 6 April 2021 Jazzy relocated to Raymond Terrace and his supervision on parole was immediately transferred from BCC to Maitland Community Corrections (MCC).
The next day, on 7 April 2021, Jazzy called Newcastle Community Corrections and informed them that he had no money to report on that date,30 however the following day, 8 April 2021, he reported to MCC and records indicate that he engaged well and appeared motivated. At that appointment, Jazzy indicated that he had a MHCP from his doctor in Sydney but he still needed to attend a doctor in Newcastle for a local referral for psychology.31 The records suggest that this was the first of only two in person attendances by Jazzy upon MCC. He was given a future appointment at MCC of 15 April 2021.
On 13 April 2021, Jazzy attended in person to see Ms Anderson at the PSFNS. He declined a referral to mental health supports stating that he had been given referrals from his doctor in Sydney. He also stated that he was reporting to MCC weekly.32 This was Jazzy’s only in person attendance with Ms Anderson.
25 Vol 2, Tab 11, Case History Notes, p103 26 Vol 2, Tab 11, Case History Notes, p104.
27 Vol 2, Tab 11, Case History Notes, p105.
28 Vol 1, Tab 10, OIMS Case Notes, p223.
29 Vol 1, Tab 10, OIMS Case Notes, p224.
30 Vol 1, Tab 10, OIMS Case Notes, p225.
31 Vol 1, Tab 10, OIMS Case Notes, p225.
32 Vol 1, Tab 7, Statement of ; Vol 7, Tab 23, PSFANS File Notes, p2.
On 15 April 2021 Jazzy failed to attend an appointment at MCC and did not answer his phone when called.33 He returned their call later that day and was told that his appointment was rescheduled for the following day.34
Jazzy attended the next day on 16 April 2021 and saw Colette Davies, a CCO who was not his designated CCO. Ms Davies recorded that Jazzy was exhibiting disordered thinking throughout the interview and that he reported a relapse on one occasion “the other day” when he used a small amount of ice.35 Jazzy reported peer pressure and voices in his head telling him to take drugs. The records note that he had taken one of his prescribed mental health medications (Zyprexa) in the waiting room and that he took another during the interview.
On the same day, 16 April 2021, Jazzy’s mother sent an SMS to Mr Plowright at BCC to advise that Jazzy was using drugs again. Mr Plowright’s evidence was that he did not recall receiving this message as he may have been on annual leave and it was an employee mobile rather than his own. He also stated that if he had received the message, he would have contacted MCC to let them know about the SMS.36 This was certainly a missed opportunity for information sharing. Employee mobiles, if unattended should be re-directed or have clear voice messages with redirection options available.
Six days later, on 20 April 2021, Jazzy did not attend his appointment with MCC as planned and did not answer his phone.37
Three days later, on 23 April 2021, Jazzy’s designated CCO from MCC Morgan McCarter attended the to look for Jazzy. He was informed that Jazzy was being evicted. The reasons given were a loud party on the first night that he stayed at the premises, followed by another loud party earlier in the week when Jazzy appeared to be under the influence of drugs and became verbally abusive and aggressive when security spoke to him. Mr McCarter knocked on Jazzy’s door and his window but there was no answer, so he left the notice of eviction.38 Ms Anderson at PSFNS was not advised that Jazzy was being evicted from the accommodation that she had helped arrange by either or MCC.
It is noteworthy that on 24 April 2021 informed Jazzy’s mother that Jazzy “got ice again about 6am so I showered and left the motel. I’m gunna have lunch with my sister in 33 Vol 1, Tab 10, OIMS Case Notes, p226.
34 Vol 1, Tab 10, OIMS Case Notes, p226.
35 Vol 1, Tab 10, OIMS Case Notes, p227.
36 David Plowright, Transcript, 6 September 2023, p50.
37 Vol 1, Tab 10, OIMS Case Notes, p227.
38 Vol 1, Tab 10, OIMS Case Notes, p228.
Newcastle. He is mental right now. I can’t stand being around him like that.”39 It was clear to family that things were deteriorating quickly.
Days later, on 28 April 2021, Jazzy telephoned MCC and apologised for not making earlier contact. Records indicate that he sounded well, engaged appropriately, and did not appear under the influence of any substances. He said he had been sleeping a lot. When challenged about the eviction notice, he denied aggression and he said that he had paid up his accommodation until 4 May 2021. He said that he had spoken to the Manager of and could secure another week from that date to give him time to get alternative accommodation if necessary.40
In a statement prepared for this inquest, recounts that Jazzy started to use ice and pot occasionally after his release to parole, and that Jazzy was using ice a couple of times a week until 28 April 2021 when he started using ice daily.41
On 2 May 2021, called an ambulance to attend where Jazzy was suffering from stomach cramps, vomiting and could not pass urine. He was taken by ambulance to John Hunter Hospital for treatment.
The following Monday, 3 May 2021, telephoned MCC to inform them that Jazzy was in hospital after a three day ice binge and was now in an induced coma.
Post mortem examination
An external post mortem examination, including toxicological analysis was conducted on 11 May 2021. The report later produced recorded the cause of death as “complications of methylamphetamine use”.
A review of the medical records found that he had been diagnosed with septicaemia, multiorgan failure, aspiration pneumonia, rhabdomyolysis, acidosis and severe shock which maximal medical management failed to arrest.
Toxicology detected amphetamine, methylamphetamine and cannabinoids. There is no dispute that his death was as a result of complications of methylamphetamine toxicity. There is also no evidence that his death was intentional, rather it occurred accidently in the context of an extended period of use.
The evidence of Community Corrections and Port Stephens Family Neighbourhood Service 39 Vol 1, Tab 7, Statement of , [27].
40 Vol 1, Tab 10, OIMS Case Notes, p228.
41 Vol 1, Tab 8, Statement of p2.
Professor Baldry gave evidence that this case load was too high for a case worker to support a complex needs client like Jazzy and that a maximum of 8-10 clients was ideal.42
Professor Baldry stated “the requirement that a community corrections officer manage/supervise dozens of clients (in David Plowright’s case) many of whom have MHD &/or CD and ensure they comply with their MH plan, their medication, their housing arrangements, their abstinence from AOD and complete programs and attend all the appointments required is unrealistic” She noted that people with complex needs, like Jazzy had, should not be left to “criminal legal agencies” such as Community Corrections to manage, they should be case-managed in the community alongside any supervision a CCO may provide. I accept her opinion on this matter.
Jazzy had been released following an in custody RMP which assessed his Level of Service Inventory – Revised (LSI-R) to determine his risk of re-offending and to designate the level of service required to address the risk. The RMP must address risk factors related to the offender and their behaviour including any risks associated with the specific area or accommodation in which they propose to reside.43 The RMP for Jazzy was conducted by the Parole Unit at Cessnock Correctional Centre on 17 February 2021 and Jazzy was determined to be tier 3/high which was the highest possible risk level and required once per week contact with the parolee and third parties and a home visit every four weeks44 There was no requirement for an inspection of an address prior to release if the parolee had previously resided at the same premises, which was the case for Jazzy residing at his mother’s home.45
The risk assessment in custody took into account both pro-social and risk factors. Jazzy’s case was difficult as there were both pro-social and risk factors at both the proposed addresses in the Burwood and the Raymond Terrace area – a complication recognised by both Mr Plowright and Professor Baldry in evidence.46 Professor Baldry gave evidence that the difficulty in assessment arose from the clear offending history in both places and the pro-social supports at both places, namely Jazzy’s mother and his partner , noting that the assessment of pro-social supports go beyond a consideration of the actual accommodation available.47 Mr Plowright gave evidence that a residence that was deemed 42 Professor Eileen Baldry, Transcript 16 November 2023, p39.
43 Vol 7, Tab 24, Statement of David Plowright, Annexure C, p3, 7.1 “Risk mitigation plans”.
44 David Plowright, Transcript, 6 September 2023, p12-14; Vol 3, Tab 12e, D5.1 Service Delivery Standards for Supervised Offenders, p74; Vol 1, Tab 9jj, Risk Mitigation Plan, p163-173.
45 David Plowright, Transcript, 6 September 2023, p26.
46 David Plowright, Transcript, 6 September 2023, p48-49; Professor Eileen Baldry, Transcript, 16 November 2023, p37.
47 Professor Eileen Baldry, Transcript, 16 November 2023, p37.
pro-social could change, which is what appeared to occur in relation to Jazzy shortly after he was released from custody.48 Mr Plowright was specifically concerned about tension arising at the family home once Jazzy indicated that he didn’t want to be there.
Mr Plowright gave evidence that Jazzy was adamant about leaving the Burwood area no matter what and as such it was the CCOs responsibility to ensure Jazzy did not re-offend or hurt anyone and that he continued to engage with the service no matter his location.49
Mr Plowright accepted that when Jazzy was residing in the Burwood area, his mother was functioning as a de facto case manager, arranging doctor’s appointments and culturally appropriate supports and encouraging Jazzy to attend his appointments. The level of assistance she provided was not something that BCC had the capacity to provide.50 He also noted that there were no culturally appropriate post-release support workers in the Burwood area.51
Mr Plowright accepted that drug relapse allowed for a CCO to direct a parolee into rehabilitation, however waitlists made the issuing of such a direction unreasonable if the parolee could not comply due to a lack of availability.52 He further noted a lack of services specific to ice residential rehabilitation, particularly in the immediate or short term.53
Mr Plowright gave evidence of the difficulty in engaging with about the proposed move in circumstances where Jazzy was expressing distress at remaining. In his view this raised concerns that the risk of offending or harm to others might be escalated. Mr Plowright spoke of his knowledge of a prior incident at the Burwood premises and was keen not to place anyone in danger if tensions grew. In any event Mr Plowright said that a CCO had no right to refuse the transfer.54
Both Mr Plowright and Mr McCarter gave evidence that CC would not breach a parolee for disclosing a single relapse into drug use or for having a positive drug test (noting the drug test that was conducted on Jazzy was negative, but may have been unsupervised).55 Rather, Community Corrections seeks to strike the right balance between policies that encourage the management of the situation in the community and the mitigation of risks in the community with automatic revocation and return to custody.56 Part of this balance at 48 David Plowright, Transcript, 6 September 2023, p30.
49 David Plowright, Transcript, 6 September 2023, p46.
50 David Plowright, Transcript, 6 September 2023, p15, 28.
51 David Plowright, Transcript, 6 September 2023, p28.
52 David Plowright, Transcript, 6 September 2023, p23; Morgan McCarter, Transcript, 7 September 2023, p20.
53 David Plowright, Transcript, 6 September 2023, p27.
54 David Plowright, Transcript, 6 September 2023, p48-49.
55 David Plowright, Transcript, 6 September 2023, p44; Morgan McCarter, Transcript, 7 September 2023, p20, 26.
56 David Plowright, Transcript, 6 September 2023, p18.
the commencement of a relationship between a parolee and a CCO is a focus upon building rapport.57 Mr McCarter gave an example of managing a relapse in the community by the CCO attempting to accelerate a parolee’s engagement in drug and alcohol counselling.58
Both Mr Plowright and Mr McCarter gave evidence that the State Parole Authority (SPA) had a preference for parolees to be managed in the community rather than moving to hasty breach action, especially if a parolee was remaining in contact with CC and exhibiting a willingness to keep engaging, as Jazzy was.59 Ms Davies, the non-designated CCO who saw Jazzy at MCC, noted that SPA reports had to be focussed on the risk of re-offence rather than risk to the parolee.60 It was an important point to make clear and in my view emphasises the need for the involvement of an independent support worker in these circumstances whose focus is on the therapeutic and social needs of the parolee, rather than on the risk of re-offence. These risks may overlap, but they remain distinct.
Mr McCarter gave evidence that, as an Aboriginal man himself, “my brothers don’t need to go to gaol more.” Mr McCarter further stated that, having worked in prisons, the decision to breach a parolee and return them to custody was a weighty decision and that if Jazzy had returned to custody he would have been released at the end of his sentence with no supervision on parole. 61
CC Policy did not require that a further RMP be conducted before Jazzy was permitted to move from Burwood to Raymond Terrace as the LSI-R done in custody was still valid.62 The policy referred to a “significant change” that would warrant the re-application of the LSIR but Mr Plowright did not consider the change of address from Burwood to Raymond Terrace as a significant change given that the address constituted only one or two points in the LSI-R and did not greatly affect the end level of risk calculated. It is important to remember that even if a further risk assessment had been conducted, there was no higher risk level to which Jazzy could have been elevated.63 He was already receiving the most intensive supervision available in the circumstances.
In assessing the risks associated with the move, it was the role of the receiving office, MCC, to update the case plan to include relevant information relating to third parties including family and treatment providers.64 Mr McCarter gave evidence that the RMP conducted in 57 Morgan McCarter, Transcript, 7 September 2023, p26-27.
58 Morgan McCarter, Transcript, 7 September 2023, p20.
59 David Plowright, Transcript, 6 September 2023, p54; Morgan McCarter, Transcript, 7 September 2023, p26.
60 Collette Davies, Transcript 7 September 2023, p47.
61 Morgan McCarter, Transcript, 7 September 2023, p27.
62 Vol 3, Tab 12a, p4, D2 Assessment Policy 2.2.2. “Ongoing Assessment”; Vol 3, Tab 12g, D7 “Transfers between offices”.
63 David Plowright, Transcript, 6 September 2023, p21-22.
64 David Plowright, Transcript, 6 September 2023, p23.
custody would be expected to be reflected in the case plan already completed by BCC and the plan subsequently done by MCC and no changes of significance would be expected across those documents.65
Prior to the move, it was the responsibility of the transferring office, BCC, to ensure all assessments and case management plans were up to date and this was done.66 With regard to the OIMS record “conduct review of breakdown of post-release plan”, Mr Plowright confirmed that this referred to an intention of BCC to work out why the plan to release Jazzy to his mother’s home had broken down in such a short period. He stated that this was not a formal process and may have just involved discussions with Jazzy and third parties.67 As noted above, the evidence of Professor Baldry was that it is common for parolees to be released to their parental home and in more than half of those cases the arrangement breaks down shortly after release and the parolee seeks to relocate.68There is little doubt that the period just after release is a particularly stressful time.
Mr Plowright gave evidence that he could not think of any circumstance in which a CCO was authorised to refuse a transfer as it was always better for a parolee to have some supervision rather than none at all.69 For example, a transfer cannot be refused due to outstanding assessments or tasks, nor can it be refused if the parolee changes address without permission.70 The role of a CCO is to prioritise community safety and to ensure that offences are not committed by making sure the parolee is supervised regardless of any outstanding tasks or even an unauthorised move.71 The aim is to remain in contact. Mr Plowright gave evidence that his main concern was that Jazzy may move without permission and lose contact with Community Corrections altogether.72
Mr Plowright accepted that the fragmentation of services provided between CCOs, community organisations such as PSFNS, and housing providers such as is not ideal.
There can be a lack of consistent communication and universal policies, as well as problems caused by the need for individual consents across different organisations to provide for proper information sharing.73 Better communication between CCOs and organisations such as PSFNS would be ideal as Mr Plowright stated that he understood Ms Anderson at PSFNS would be taking on a role similar to that had undertaken in Burwood including 65 Morgan McCarter, Transcript, 7 September 2023, p29.
66 David Plowright, Transcript, 6 September 2023, p31; Vol 3, Tab 12g, D7 Transfers between Offices, 7.2 and 7.3, p95-96; Exhibit 3, Burwood CC case plan for Jazzy dated 12 March 2021.
67 David Plowright, Transcript, 6 September 2023, p42.
68 Professor Eileen Baldry, Transcript, 16 November 2023, p37-38.
69 David Plowright, Transcript, 6 September 2023, p35.
70 Vol 3, Tab 12g, D7 Transfers between Offices, p97-98; David Plowright, Transcript, 6 September 2023, p3435.
71 David Plowright, Transcript, 6 September 2023, p22, 34-35.
72 David Plowright, Transcript, 6 September 2023, p48-49.
73 David Plowright, Transcript, 6 September 2023, p38.
arranging doctor’s appointments and drug treatment. While Ms Anderson gave evidence that her involvement was minimal and that she understood that MCC would be arranging these things.74
Mr Plowright welcomed more training in mental health for CCOs,75 as well as endorsing the Ice Inquiry recommendations 99 and 102 regarding dedicated case management, safe and stable housing, primary and mental health services, drug treatment on a health needs basis as measures that would have helped Jazzy and which CC was not presently resourced to provide.76
Ms Anderson, a Senior Practitioner from PSFNS, gave evidence about the assistance she provided to Jazzy in obtaining accommodation at She said provided two types of accommodation, one being TA that the Department of Housing utilise and another being a weekly rate for more permanent accommodation. In April 2021 Jazzy went to under the second type of accommodation, namely the weekly more permanent rate which, according to Ms Anderson, had no involvement with the Department of Housing or any agency receiving funding from them. Jazzy had been offered that arrangement in 2021 due to being housed there via the Link2home service the previous year.77 the Manager of gave evidence confirming that, whilst he could not recall details of the arrangement with Jazzy upon his second stay at , if a person had previously stayed as a Housing client then they may be permitted to stay again as a weekly rental client.78 Ms Anderson gave evidence that there were people that she was aware of who had been living at on the more permanent rate for over two years.79
Ms Anderson had a caseload of around 10 clients at any one time, and she was also tasked with overseeing 7 case workers. All her clients would fall into the category of complex support needs like Jazzy including having mental health issues, brain injury and substance use issues.80
Ms Anderson’s service was not mandated and as such, whilst she could offer and recommend assistance to clients, she could not pursue them to enforce compliance.81 CCOs would take on that role, however PSFNS could not inform MCC that a parolee was not attending treatment as suggested unless the parolee had consented to such disclosure 74 David Plowright, Transcript, 6 September 2023, p45.
75 David Plowright, Transcript, 6 September 2023, p52.
76 David Plowright, Transcript, 6 September 2023, p52.
77 Kylee Anderson, Transcript, 6 September 2023, p62-63.
78 Transcript, 16 November 23, p7-8.
79 Kylee Anderson, Transcript, 6 September 2023, p63.
80 Kylee Anderson, Transcript, 6 September 2023, p64.
81 Kylee Anderson, Transcript, 6 September 2023, p64.
which Jazzy had not yet done.82 Ms Anderson had assumed in 2021 that MCC was arranging mental health and drug and alcohol services for Jazzy when he arrived in Raymond Terrace.83 She told the court that it was not PSFNS’s responsibility to take clients to appointments, however if a client requested the service, she would have been happy to assist.84 I accept PSFNS had a limited role in assisting Jazzy get his own accommodation on this occasion and that the organisation had no further obligations.
PSFNS is not bound by any of the polices of CC and there was no Memorandum of Understanding (MOU) between MCC and PSFNS in 2021, nor was there clear communication. Both Ms Anderson and Mr McCarter welcomed better communication and an MOU between the two organisations, accepting that consent issues restrict the flow of information from MCC to PSFNS and .85 The court was informed that some improvement in communication has occurred in the local area in the last six months due to a regular Monday Hub meeting at attended by both MCC and PSFNS.86 Ms Lane, the current manager of MCC saw no impediment to formalising an MOU for better communication and collaboration between PSFNS and MCC.87 Consent as to informing TA providers about the clients staying at the premises was an issue acknowledged by the Department of Housing.88
When Ms Anderson spoke to and saw Jazzy in 2021, he appeared mentally stable. He told her about the doctors that he had been referred to by his Sydney GP and she did not detect any signs of drug or alcohol use.89 However, if she had seen a decline in his mental health or indications of drug use there were few options available for referral and waiting lists were high. There was one local Salvation Army drug and alcohol counsellor, and residential rehabilitation was only available in Newcastle, Belmont, the Central Coast or Cessnock but each had extended waiting lists. Both Ms Anderson and Mr McCarter stated that there had been no real improvements seen in their area since Jazzy’s death or since the Ice Inquiry”.90
Ms Anderson was never advised that Jazzy had received an eviction notice from and would welcome a protocol for this type of information sharing between accommodation providers, PSFNS and MCC.91 82 Kylee Anderson, Transcript, 6 September 2023, p65.
83 Kylee Anderson, Transcript, 6 September 2023, p67.
84 Kylee Anderson, Transcript, 6 September 2023, p68.
85 Kylee Anderson, Transcript, 6 September 2023, p65-66; Morgan McCarter, Transcript, 7 September 2023, p16; Transcript 16 November 2023, p17.
86 Kylee Anderson, Transcript, 6 September 2023, p67.
87 Louise Lane, Transcript 7 September 2023, p55.
88 Wilma Falcone, Transcript, 16 November 2023, p25-26.
89 Kylee Anderson, Transcript, 6 September 2023, p69-70.
90 Kylee Anderson, Transcript, 6 September 2023, p71; Morgan McCarter, Transcript, 7 September 2023, p22.
91 Kylee Anderson, Transcript, 6 September 2023, p72.
Mr McCarter was Jazzy’s designated CCO at MCC, however he never met Jazzy and only spoke to him over the phone on one occasion on 28 April 2021.92 Jazzy was seen by other MCC CCOs, namely Mr Kowalski and Ms Davies. In fact, OIMs records show that Jazzy saw or spoke to different officers each time he was in contact with MCC. Both Mr McCarter and Ms Davies accepted that best practice would be to have continuity for a parolee especially one with complex support needs like Jazzy. Mr McCarter noted that at times Jazzy reported to the office outside his allotted reporting appointments and that the practice at MCC was not to turn parolees away if their CCO was unavailable but rather to have the parolee seen by another CCO. Ms Davies gave evidence that in her view parolees who turned up outside allotted appointments should be redirected to report when their designated CCO was available.93 There may be benefits of each approach.
Mr McCarter stated that his practice prior to the first appointment with a parolee as designated CCO was to review the case plan from the prior office and consider the referral services available and appropriate for the parolee, as well as gaining consent to contact the GP to substantiate appointments and referrals. The records show that the case plan for Jazzy from BCC was allocated to Mr McCarter on 26 April 2021, but Mr McCarter had not updated the case plan as there had not been enough time with Jazzy to properly commence the process of engagement.94 Mr McCarter told the court that he would have embraced contact with Jazzy’s mother if he had consent from Jazzy to do so.95
Mr McCarter gave evidence (consistent with that of Mr Plowright) that a CCO’s role was not to tell a parolee that they could not live at a certain address, but rather to assist them in managing the environment they were in.96 In any event, was the only option available in the area at the time for people who were homeless or transient97 and Jazzy was unable to reside with due to the terms of the AVO.
Mr McCarter was unaware of Jazzy’s impending eviction from until he attended the premises in person and was advised by the manager. If Jazzy had been at the premises at the time, then Mr McCarter’s evidence is that he would have supported him to resolve the issue with the manager.98 92 Morgan McCarter, Transcript, 7 September 2023, p7, 16.
93 Morgan McCarter, Transcript, 7 September 2023, p6; Collette Davies, Transcript, 7 September 2023, p4345.
94 NSW Dept of Corrective Services Maitland Offender Case Plan, Exhibit 6; Morgan McCarter, Transcript, 7 September 2023, p24-25.
95 Morgan McCarter, Transcript, 7 September 2023, p17-19.
96 Morgan McCarter, Transcript, 7 September 2023, p11, 30-31.
97 Morgan McCarter, Transcript, 7 September 2023, p12-13, 31.
98 Morgan McCarter, Transcript, 7 September 2023, p13.
Ms Lane, the manager of MCC, gave evidence about some potential, possibly more appropriate options for Jazzy. Jazzy would have been eligible for referral by his CCO to the Initial Transitional Support (ITS) worker Housing Plus, however there were only 12 places in the Maitland, Cessnock and the Raymond Terrace area.99 As for the Transitional Supported Accommodation (TSA) service, which provided a specific caseworker support program, there was one house in Newcastle with only five beds available servicing the Raymond Terrace area.100 Services such as the Extended Reintegration Service (ERS) were not available to Jazzy as they were only available to those in the Southwestern Sydney area.101
Mr McCarter and Ms Lane’s evidence (consistent with that of Ms Anderson) was that there were also extremely limited services in the Raymond Terrace area in terms of drug treatment, attending a local GP for a mental health care plan and there were no culturally appropriate services.102 Mr McCarter had assumed it would be his role as the designated CCO to arrange referrals and would not have assumed that PSFNS was undertaking those tasks, but he had not had enough time with Jazzy to make such arrangements.103
Mr McCarter agreed with Ms Anderson regarding the difficulties of consent for communication between organisations and noted that best practice was to obtain a signed consent from the client as soon as the other service provider was identified.104
Mr McCarter gave evidence that the decision about how to deal with an admission of substance use was the responsibility of the designated CCO and not another CCO who may have seen the parolee due to their attendance outside a scheduled appointment. He stated that the non-designated case officer would not be in a position to weigh the entirety of the situation.105 Mr McCarter gave evidence that if Jazzy had been present when Mr McCarter attended at and found out about the eviction notice, he would have accelerated efforts to get Jazzy into the Mental Health and Substance Use Service at the Mater Hospital in Waratah, in light of Jazzy’s recent admission of drug use. However, the reality of waitlists would have meant that Jazzy was not engaged for at least a number of weeks.106 In my view the lack of support for those struggling with mental health issues and ice addiction needs to be addressed. The fact that the court heard that the situation on the 99 Louise Lane, Transcript 7 September 2023, p87-88.
100 Louise Lane, Transcript 7 September 2023, p59-60.
101 Louise Lane, Transcript 7 September 2023, p60.
102 Morgan McCarter, Transcript, 7 September 2023, p11; Louise Lane, Transcript 7 September 2023, p55.
103 Morgan McCarter, Transcript, 7 September 2023, p16-17.
104 Morgan McCarter, Transcript, 7 September 2023, p15.
105 Morgan McCarter, Transcript, 7 September 2023, p21.
106 Morgan McCarter, Transcript, 7 September 2023, p21-22.
ground does not feel improved after the very important work completed by the Ice Inquiry is of significant concern.107
Ms Davies, the non-designated CCO at MCC who saw Jazzy when he reported in person on 16 April 2021 gave evidence that he appeared to have disordered thinking and that he told her that he heard voices telling him to take drugs and that he had taken a small amount of ice “the other day”. Ms Davies gave evidence that she did not deem it necessary to take any action at that time as he appeared stable, was medicated for his mental health issues and he had reported drug use on one occasion only. She also stated that she was not the most appropriate person to determine what action should occur as she was not Jazzy’s designated CCO.108 Further, the policy regarding directions for drug testing note that a direction is not appropriate if an offender admits use and test results would not change the CCO’s response.109 Applied to Jazzy, the response if a drug test had returned a positive result would have been the same, that is to continue to manage him in the community and support him to remain drug free. Mr McCarter had intended to assist him to do this when he met with Jazzy, but unfortunately Jazzy did not attend his appointment and the follow up by Mr McCarter at did not result in a face-to-face meeting with Jazzy.
I note for completeness that Covid-19 measures were in place for some of the relevant period. This may have impacted the service delivery to Jazzy from time to time, including affecting the availability of Jazzy’s designated CCO at MCC when he attended outside scheduled appointments.110
Neither Mr Plowright nor Mr McCarter considered electronic monitoring appropriate for Jazzy.111 I accept their view. Mr McCarter gave evidence that electronic monitoring was not something considered lightly by a CCO and would require a clear reason. Mr McCarter gave the example of the need to monitor a parolee pursuant to an AVO or a parolee which the SPA had specifically directed must be subject to electronic monitoring.112 Evidence of Department of Community and Justice on accommodation
One of the clear difficulties facing Jazzy on his release from custody was his need for supported accommodation. While his mother was always open to providing Jazzy with a supportive home, once he decided to leave that accommodation, Jazzy was in a precarious 107 Kylee Anderson, Transcript, 6 September 2023, p71; Morgan McCarter, Transcript, 7 September 2023, p22.
108 Collette Davies, Transcript, 7 September 2023, p39-40.
109 Collette Davies, Transcript, 7 September 2023, p42; Vol 3, Tab 12i, p114 “Policy E2 Drug Testing 2.2.2”.
110 See for eg Morgan McCarter, Transcript, 7 September 2023, p9; Collette Davies, Transcript, 7 September 2023, p38; Louise Lane, Transcript, 7 September 2023, p51-52; Exhibit 7, MCC Stage 3 Covid roster.
111 David Plowright, Transcript, 6 September 2023, p29; Morgan McCarter, Transcript, 7 September 2023, p19-20.
112 Morgan McCarter, Transcript, 7 September 2023, p19-20.
and dangerous situation which was always going to place him at significant risk. Prior to assessing the accommodation resources and options that may have been available for CC officers to offer Jazzy, it was necessary to grapple with the operation of the public and social housing landscape in NSW. The evidence provided established that the sector is both fragmented, difficult to navigate and under-resourced.
The court was informed that The Department of Communities and Justice – Housing (“DCJ”) provides, and works with service agency partners and individuals to provide, a range of housing solutions for the private rental market and social housing.113 Social housing refers to long-term housing assistance whereby DCJ provides secure and affordable rental housing for people on low incomes with housing needs, including those exiting or who have recently exited custody.114 Social housing incorporates Public Housing, Community Housing and Aboriginal Housing.115 The Land and Housing Corporation (“LAHC”) own properties used for social housing116 and DCJ is responsible for the management of these properties for Public Housing. DCJ also fund Community Housing Providers (“CHPs”) to manage Community Housing in specific areas. 117 DCJ or CHPs can manage Aboriginal Housing.118
DCJ oversees the Housing, Disability, District Services and Disaster Welfare (“HDDSDW”) as well as the Strategy, Policy and Commissioning (“SPC”).119 HDDSDW oversees Housing Statewide Services (“HSS”) and the Housing Contact Centre (“HCC”). Link2Home, a housing service delivered directly to clients, is delivered by HCC.120 SPC oversees Housing, Homelessness, Disability and Seniors (incorporating Homelessness Programs and the Community Housing Branch) as well as FACS Insights, Analysis and Research.121 Of note, HSS is responsible for overseeing DCJ housing policies and procedures across NSW.122
It was immediately clear that there was no simple housing solution for Jazzy. Securing long term public housing is a near impossible dream for someone in Jazzy’s situation. The court was informed DCJ’s Housing Pathways is the overarching framework which informs how applications for housing assistance are managed in NSW. Housing assistance through 113 NSW Government, DCJ Housing, 5 September 2023, found: https://www.service.nsw.gov.au/nswgovdirectory/dcj-housing 114 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [6]; Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, [8].
115 Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, [8]; NSW Government, DCJ Housing, 5 September 2023, found: https://www.service.nsw.gov.au/nswgovdirectory/dcj-housing 116 Wilma Falcone, Transcript, 16 November 2023, p24.
117 Ibid p25.
118 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [6].
119 DCJ Housing Related Witnesses Organisational Structure.
120 Ibid; Wilma Falcone, Transcript, 16 November 2023, p20.
121 DCJ Housing Related Witnesses Organisational Structure.
122 Wilma Falcone, Transcript, 16 November 2023, p20; Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, [3].
Housing Pathways includes providing co-ordinated information about housing assistance, a standard assessment process and a single waiting list, namely the NSW Housing Register.123 This register lists applicants in order according to their required housing location, approval category and approval date.124 Further, it is segmented into priority and general categories which determines housing allocation.125
Clients, including clients who are in custody or who have recently been released can apply for social housing through the Housing Pathways application process.126 If they are eligible, they are placed on the NSW Housing Register until a property becomes available.127 It is noted that wait times for such properties are lengthy. For example, in Raymond Terrace, the expected wait time for a studio/1-bedroom apartment is 10+ years.128 The kind of wait time involved meant that it was of little relevance to Jazzy. There is a clear and pressing need for more public housing.
Given the appalling shortage of public housing for those in need, Government provides a patchwork of stop gap measures. It is beyond the scope of these reasons to assess each option or set out in detail the fragmented approach that has developed in lieu of providing a comprehensive solution to homelessness in NSW.
The court received evidence about a variety of programs which DCJ offers in partnership with CHPs129or which it funds non-government organisations to provide. The court was informed that the Specialist Homelessness Services (“SHS”) program is the NSW Government’s primary response to homelessness.130 DCJ, and the Australian Government as a co-contributor, 131 fund non-government organisations (“SHS providers”),132 currently until 30 June 2024,133 to deliver a range of services to support individuals who are homeless or at risk of becoming homeless,134 including individuals who have recently been released from custody or who have previously exited custody.135 This program is managed by DCJ’s 123 Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, [4]-[5].
124 Ibid [26].
125 Ibid [26].
126 Ibid [23].
127 Ibid [24].
128 NSW Government Communities & Justice, ‘Expected waiting times’, 17 December 2020 https://www.facs.nsw.gov.au/housing/help/applying-assistance/expected-waiting-times 129 See for example Exhibit 12, Together Home Program as discussed in the statement of Humair Ahmad, [10] 130 Vol 7, Tab 28, Statement of Matthew Barden, [6].
131 Vol 7, Tab 29A, Second Statement of Matthew Barden, 28 August 2023, [11].
132 Vol 7, Tab 28, Statement of Matthew Barden, 19 June 2023, [3].
133 Ibid [6].
134 Vol 7, Tab 29A, Second Statement of Matthew Barden, 28 August 2023, [3].
135 Vol 7, Tab 28, Statement of Matthew Barden, 19 June 2023, [3], [5]; Exhibit 12, Statement of Humair Ahmad, 15 November 2023, p105; Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [3].
Strategy, Policy and Commissioning who report to DCJ Housing and Homelessness Strategy Steering Committee.136
An individual may access the SHS program through a variety of pathways such as through a referral from Link2Home, the Domestic Violence line, a team using an assertive outreach approach, DCJ137 or a SHMT CHP.138 The SHS program can also be accessed through self-referral, or an individual may be referred by a third party.139
An individual is eligible for the SHS program if they are homeless or at risk of homelessness.
An individual is ‘homeless’ if they are living in non-conventional accommodation such as living on the streets, or they are living in short-term or emergency accommodation such as in refuges or they are couch surfing.140 An individual is at ‘risk of homelessness’ if they are at risk of losing their accommodation due to a range of factors such as financial stress, mental health issues and family or relationship breakdown.141
An individual may not be eligible for a specific SHS provider they accessed as SHS providers may have a specific delivery model and target client group(s).142 For example, some SHS providers, such as Getting Out Finding Home and Glebe House Homelessness Support Service for Men Exiting Custody, focus specifically on assisting clients who are experiencing a risk of homelessness upon exiting custody.143 However, the SHS program employs a ‘No Wrong Door’ approach meaning an individual will receive or be assisted to receive support wherever they access an SHS service provider.144
If DCJ is unable to refer clients to the SHS program, they may refer clients to another service such as Link2Home or refer them to their local DCJ Housing Office to secure TA145 such as in a hotel and motel.146 It is noted that a client remains eligible for SHS accommodation and support services irrespective of the amount of TA they have received.147
It appears clear that some of the services offered by SHS providers or through the Reintegration Housing Support Program (RHSP) are positive initiatives. It was reported that 136 Vol 7, Tab 29A, Second Statement of Matthew Barden, 28 August 2023, p41.
137 Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, [14].
138 Vol 7, Tab 29A, Second Statement of Matthew Barden, 28 August 2023, p26-27.
139 Ibid p26-27.
140 Vol 7, Tab 29A, Definition by the Australian Institute of Health and Welfare – Second Statement of Matthew Barden, 28 August 2023, p21.
141 Ibid p22.
142 Vol 7, Tab 29A, Second Statement of Matthew Barden, 28 August 2023, p21.
143 Vol 7, Tab 28, Statement of Matthew Barden, 19 June 2023, [4].
144 Ibid [4]; Vol 7, Tab 29A, Second Statement of Matthew Barden, 28 August 2023, p27.
145 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [4]; Vol 7, tab 29A, Second Statement of Matthew Barden, 28 August 2023, [7].
146 Wilma Falcone, Transcript, 16 November 2023, p22.
147 Vol 7, Tab 29A, Second Statement of Matthew Barden, 28 August 2023, [13].
531 SHS clients leaving custody in the 2021-2022 reporting year were provided with SHS accommodation148. The court heard a little about the service offered by the Community Restorative Centre (CRC) through this program. The Reintegration Housing Support Program (“RHSP”) is delivered by the Community Restorative Centre (“CRC”) to provide wrap-around psychosocial support to individuals leaving custody who are at risk of homelessness.149 The program connects its clients with in-reach services prior to their release and immediately following their release from custody and aims to improve their wellbeing, long term housing and reduce recidivism.150 This program provides three months pre-release support and nine months post release support for inmates who are over 18, at risk of homelessness upon exiting custody, have a mental health or cognitive problem, issues with alcohol and drugs and are on a community correction order.151
The RHSP was initially launched in July 2021152 and is a partnership between Community Corrections, NSW Health and Link2Home.153 The CRC is funded by DCJ’s Strategic Policy and Commissioning154 to provide case management for up to 20 clients per year155 until 30 June 2024.156 The RHSP currently operates in six locations across NSW,157 with two CRC support workers based in each of the following DCJ Housing Offices: Inner Sydney, Western Sydney, South-Western Sydney, Western NSW, Illawarra and the Hunter area.158 As at August 2023, 517 clients had been supported through the RHSP, including 103 active clients and 414 who had exited the program.159 The RHSP has been recognised as a “very successful program because it’s that hands on support.”160 From what I have seen the program should be supported and enlarged.
Mr Nelson Tilbrook, Manager Strategic Partnerships Directorate, Corrective Services NSW, gave further evidence regarding the contracting of non-government organisations to provide services and programs for Corrective Services clients in custody and the community, as well as the relationship between Corrective Services and the Department of Housing to ensure their mutual clients have access to good housing outcomes.161 148 Vol 7, Tab 29A, Second Statement of Matthew Barden, 28 August 2023, [11].
149 Email from Wilma Falcone, Information regarding RHS Program, 16 November 2023, p1.
150 Ibid.
151 Nelson Tilbrook, Transcript, 7 September 2023, p66.
152 Email from Wilma Falcone, Information regarding RHS Program, 16 November 2023, p1.
153 Nelson Tilbrook, Transcript, 7 September 2023, p66.
154 Wilma Falcone, Transcript, 16 November 2023, p31-32.
155 Nelson Tilbrook, Transcript, 7 September 2023, p66.
156 Email from Wilma Falcone, Information regarding RHS Program, 16 November 2023, p1.
157 Wilma Falcone, Transcript, 16 November 2023, p31-32.
158 Email from Wilma Falcone, Information regarding RHS Program, 16 November 2023, p1.
159 Email from Wilma Falcone, Information regarding RHS Program, 16 November 2023, p1-2.
160 Wilma Falcone, Transcript, 16 November 2023, p31-32.
161 Nelson Tilbrook, Transcript, 7 September 2023, p63.
Mr Tilbrook gave evidence that the ERS program provided a 12 month support program which consisted of 3 months pre-release support and nine months post. Eligibility requirements included a risk of homelessness upon exiting custody, mental health or cognitive impairment as well as alcohol and drug issues. Unfortunately, the capacity is only 20 clients per year and is limited to Southwest Sydney (Fairfield, Liverpool, Bankstown, Campbelltown and Camden) as operated by the Community Restorative Centre (CRC), a non-government organisation.165
In November 2023, NSW Health announced a new Post Custodial Support (PCS) program funded as part of the NSW Government response to the Ice Inquiry. The PCS will provide intensive and comprehensive treatment and support for people leaving custody who have a history or risk of harmful drug and alcohol use. Assessment and care planning will begin up to 3 months before the person’s release from custody and continue for us to 12 months post-release166. While it is too early to assess the efficacy of such an initiative, its introduction is strongly supported.
DCJ submitted that at first instance it will seek to refer a client experiencing homelessness or at risk of homelessness to a SHS and in circumstances where a SHS is not available a client may be referred to TA. I accept that but given the capacity of these kinds of specialist programs, there appears in practise to be an over-reliance on temporary accommodation for those exiting custody who are at risk of homelessness.
Temporary accommodation (“TA”) refers to short-term accommodation167 in low-cost motels or caravan parks168 provided to individuals who are homeless or at risk of homelessness, 162 Nelson Tilbrook, Transcript, 7 September 2023, p63-64.
163 Nelson Tilbrook, Transcript, 7 September 2023, p65.
164 Nelson Tilbrook, Transcript, 7 September 2023, p63.
165 Nelson Tilbrook, Transcript, 7 September 2023, p66-67.
166 Nelson Tilbrook, Transcript, 7 September 2023, p60-61, 66.
167 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [4].
168 Ibid [4].
who have secured a housing solution but are temporarily homeless or who are in a DCJ or CHP managed property but are unable to stay in the property.169
TA is provided by commercial operators which are paid on a fee for service basis.170 DCJ Housing is effectively a user of a commercial accommodation facility.
The court was informed that the provision of TA serves as a bridge between accommodation171 to give individuals a chance to secure alternative longer term accommodation, whether that be crisis accommodation or a private rental,172 or to seek support from SHS providers.173 There is no specific waiting list for clients to receive assistance to access TA.174
Clearly TA is no longer just a “bridge”, for some disadvantaged clients it is a negative and extended holding pattern. Previously, TA could not be provided for more than 28 days in a 12-month period other than in exceptional circumstances.175 However, this cap was removed on 12 July 2023.176 Other changes regarding TA eligibility included an increase in the ‘cash asset’ limit from $1,000 to $5,000 and the removal of a cash asset limit for individuals escaping domestic and family violence. 177 Further, clients are no longer required to contribute to the cost of TA.178 DCJ Housing frontline staff were notified of these changes by the Housing Pathways Notice issued on 13 July 2023.179 While I see the clear need to remove the cap and introduce these changes, I have no doubt this will also mean many of our disadvantaged community members are left for months in motel and other sub-standard accommodation.
The court was informed that DCJ uses over 300 TA providers across NSW.180 As of 7 November 2023 there were 323 TA providers across NSW of which 226 were classified as motels/hotels. The court was informed that in 2022-2023, 26 149 households were assisted with TA. Many of these would be living in motels or hotels for extended periods.
169 Manage Inspections of Temporary Accommodation Properties, p1.
170 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023 [11].
171 Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, p35.
172 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [4].
173 Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, [18].
174 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [10].
175 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [4].
176 Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, [12].
177 Ibid.
178 Ibid.
179 Ibid.
180 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [11].
DCJ also reported that often TA options are limited in specific locations due to costs being prohibitive or due to service providers not wishing to conduct business with DCJ as a result of negative experiences with former DCJ clients.181
Following initial TA being provided to a client, that client is required to attend a DCJ Housing or CHP office to complete a housing needs assessment, upon which, if necessary, staff will assist the client to find longer term accommodation.182 An extension of TA for a client may be declined if they do not meet certain responsibilities such as abiding by the rules of the accommodation facility or not leaving the accommodation in good order.183 TA providers are also expected to advise DCJ Housing if a client does not attend their premises, engages in antisocial or illegal behaviour or if client causes damage to premises.184
It is important to note that when Jazzy made the decision to move from his mother’s home, he ended up in accommodation that he had previously been given as a TA option. However on this occasion he obtained the housing himself through his former caseworker.
TA in motels and caravan parks is often provided to clients by independent185 commercial operators. 186 DCJ and CHP have a commercial relationship with such providers and pay for TA on a fee for service basis or at a nightly rate.187 However, at times DCJ Housing or a CHP may negotiate TA for longer periods for clients at a reduced cost.188 In Jazzy’s case he appears to have gone to a previous caseworker and they used their ongoing relationship with a TA provider to get him accommodation quickly as a private arrangement.
The court heard that DCJ Housing Offices and CHPs are front line, client facing offices across NSW. Staff in these offices assist clients with their housing needs including extensions for temporary accommodation (“TA”) placements, preparing TA case plans, following up on referrals sent to Specialist Homelessness Services (“SHS”) & non-SHS providers and assisting clients with NSW Housing products such as housing applications, rental subsidies and bond loan applications.189
The Community Housing Branch is comprised of 30 staff members who are responsible for managing relationships between DCJ and approximately 80 Community Housing Providers 181 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [11].
182 Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, [19].
183 See Vol 7, Tab 29D, Part 3.6 of the Rentstart Assistance Policy, Second Statement of Wilma Falcone, 30 August 2023, [15]-[17].
184 Vol 7, Tab 29D, Second Statement of Wilma Falcone, 30 August 2023, [39].
185 Exhibit 10, Second Statement of Daryn Fallshaw, 10 November 2023, [18].
186 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [11]; Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, [18]; Exhibit 12, Statement of Humair Ahmad, 15 November 2023, [16].
187 Vol 7, Tab 29, First Statement of Wilma Falcone, 27 June 2023, [11]; Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, [18]; Exhibit 12, Statement of Humair Ahmad, 15 November 2023, [16].
188 Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, [21].
189 Exhibit 10, Second Statement of Daryn Fallshaw, 10 November 2023, [7].
in Social Management Transfer areas (“SHMT CHPs”) including overseeing contracts between them, managing funding and overseeing the delivery of other DCJ programs delivered by CHPs.190 This branch serves as a direct contact for CHPs in relation to DCJ related matters including dealing with all community housing related correspondence and the handling of complaints.191 The Community Housing Branch meet with SHMT CHPs quarterly as a group to discuss issues as they arise and provides updates of DCJ business such as new or changes to existing products, policies or procedures related to the delivery of housing services.192
191 Ibid [4]-[6].
192 Ibid [8].
193 Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, p. 3.
194 Ibid [4].
195 Ibid [4].
196 Exhibit 12, Statement of Humair Ahmad, 15 November 2023, [3].
197 Ibid p74.
198 Ibid p75.
199 Exhibit 12, Statement of Humair Ahmad, 15 November 2023, p72.
200 Ibid [10], p75; Vol 7, Tab 29A, Second Statement of Matthew Barden, 28 August 2023, [12].
201 Exhibit 12, Statement of Humair Ahmad, 15 November 2023, p79.
to notify DCJ partners including the Client Referral Assessment Group (“CRAG”) to manage referrals.202
CHPs are also encouraged to establish relationships with the Local Health District should a referral to the local health team be required.203 Further, CHPs are responsible for identifying possible TA providers in their location and managing their relationship with such providers.204 To receive funding and assistance, CHPs must be registered under the National Regulatory System for CHPs.205 DCJ also provide training to CHPs via the Community Housing Industry Association NSW206 and annual accountability meetings are held with CHPs.207
In the local area to which Jazzy moved after he left his mother’s home, the relevant CHP was Hume Community Housing Association (“Hume Housing”) .The court was informed that Lucy Andrews is the Manager of Housing Options at Hume Housing.208 Hume Housing is contracted by DCJ to deliver housing assistance in the Southern Hunter New England Area, primarily in the Maitland and Port Stephens local government areas.209 The management of properties in these areas was transferred from DCJ to Hume on 2 September 2019210 on a 20-year lease so now Hume Housing is responsible for tenancy and services in that location.211 As such, there is no DCJ Housing presence in that location.212 Hume Housing use DCJ’s Homes Operational Management Extended Services (“HOMES”) system to enter details of the services delivered.213
Hume Housing are responsible for primarily managing relationships with Temporary Accommodation (TA) providers in their management area.214 For example, Hume Housing manage the relationship with where Jazzy was living at the time of his death. is a TA provider.215 Like many other TA providers, it is an independent business and, as such, Link2Home pay for the use of their facilities.216 If a complaint is made about , this will be forwarded to Hume Housing for action as it is within their 202 Ibid p80-81.
203 Ibid p95.
204 Ibid [15].
205 Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, p. 5.
206 Exhibit 12, Statement of Humair Ahmad, 15 November 2023, [30].
207 Ibid [28].
208 Exhibit 10, Second Statement of Daryn Fallshaw, 10 November 2023, [10]; Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, [4].
209 Exhibit 12, Statement of Humair Ahmad, 15 November 2023, [7], p101.
210 Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, [5].
211 Wilma Falcone, Transcript, 16 November 2023, p22.
212 Ibid p21.
213 Exhibit 12, Statement of Humair Ahmad, 15 November 2023, p52-53.
214 Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, [5].
215 Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, [5].
216 Exhibit 10, Second Statement of Daryn Fallshaw, 10 November 2023, [18]; Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, [19].
management area.217 For example, if Housing Statewide Service receive a complaint about , the court was informed that they would divert the complaint to Hume Housing.218 If Hume Housing approached Housing Statewide Services regarding a complaint about , Housing Statewide Services could provide general policy advice.219
Hume Housing is also responsible for ensuring that there are adequate TA providers in their area. For example, the court was informed that on 2 March 2022, a site inspection conducted at revealed that it was not suitable for TA and needed to be removed from VMS immediately until further notice.220 Within 10 minutes from receipt of this email by Link2Home, was no longer ‘ACTIVE’ in the VMS.221 As this resulted in Hume Housing not having any TA providers in the Port Stephen’s area, a ‘road show with Link2Home’ was organised whereby DCJ representatives travel to a particular region to source and locate additional TA service providers. In this case, Hume Housing was contracted by DCJ to perform this ‘road show’ and DCJ representatives met with Hume Housing to provide guidance as to how to engage and cultivate working relationships with TA providers.222 The court was informed that following a visit of the facilities and a meeting with the manager of on 10 March 2022, Link2Home were notified that could be used as a TA service provider for DV clients or for referrals from the NSW Police Force. As such, was updated in the VMS as ‘ACTIVE’ within these parameters of usage.223
I note that it was somewhat perplexing and disturbing that the manager of told this court, in direct conflict with the departmental evidence that he was unaware of the premises ever having been removed from the register. I will return to the state of the premises at shortly.
the manager of , confirmed that the premises had transitioned from providing motel services to the broader public to being a facility that primarily provided accommodation for Department of Housing clients.224 Whilst accepting that it was not ideal, Ms Falcone gave evidence that the Department of Housing had been using motels since around 1997 due to demand outstripping supply and that this demand has only increased since 1997 so that approximately 2,100 households were in TA on any given day.225 The number of persons exiting custody to TA for the year 2021/2022 was 1,603, many of whom 217 Exhibit 9, Third Statement of Wilma Falcone, 19 October 2023, [8].
218 Ibid [9].
219 Ibid [10].
220 Exhibit 10, Second Statement of Daryn Fallshaw, 10 November 2023, [10].
221 Exhibit 10, Second Statement of Daryn Fallshaw, 10 November 2023, [11].
222 Exhibit 10, Second Statement of Daryn Fallshaw, 10 November 2023, [10].
223 Ibid [12].
224 Transcript, 16 November 2023, p6-7.
225 Wilma Falcone, Transcript, 16 November 2023, p29-30.
would have complex support needs like Jazzy and this demand was nowhere near the limited capacity of the ERS program which can only 20 persons per year.226 The expert evidence
The inquest heard from Professor Eileen Baldry, Emeritus Professor of Criminology at the University of NSW who has had many years of experience reviewing how people with mental health disorders and cognitive disability (MHDCD) are managed by criminal legal agencies (police, courts, prisons and CC). She has conducted in depth research with Indigenous peoples and communities regarding MHDCD and criminal legal agencies and researched community sanctions in NSW.227
Professor Baldry was very critical of the assistance offered to Jazzy on release. Her criticisms were not of individual CC officers or community housing support workers, instead she drew the court’s attention to the long term and systemic failure to provide the kind of comprehensive “wrap-around” support which could have addressed Jazzy’s mental health, cognitive and AOD issues, using a trauma informed and culturally appropriate framework.
She drew the court’s attention to the fact that the problems are well known and have been the subject of past inquiries and commissions. She stated “If key recommendations of the Royal Commission into Aboriginal Deaths in Custody (RCIADC), The NSW Law Reform Commission’s Cognitive and Mental Impairments Inquiry and the ICE Inquiry had been fully implemented, [Jazzy] may not have ended up in these most tragic circumstances.228 I accept her view.
227 Professor Eileen Baldry, Transcript, 16 November 2023, p34.
228 Vol 7, Tab 30, Expert report of Professor Eileen Baldry, p8.
229 Vol 7, Tab 30, Expert report of Professor Eileen Baldry, p7.
230 Vol 7, Tab 30, Expert report of Professor Eileen Baldry, p6; Professor Eileen Baldry, Transcript, 16 November 2023, p42, 49.
(3) CCOs need more services and resources in the community to which to refer people with complex support needs so that they can receive the integrated social and health services they require;231 (4) Red flags such as missing appointments, drug relapse and report of “sleeping a lot” would ideally have resulted in MCC (noting the lack of resources and funding that CCOs face) attending earlier and seeing Jazzy in person. However the consistent specialised case worker model like CRC that allows for a civil society health focussed approach, rather than criminal justice supervision, which is focussed on managing community safety by addressing risk of offending and is bound by legislation governing CC, would have been better placed to meet these red flags;232 (5) Breaching Jazzy’s parole in this context was not ideal and it would merely repeat the cycle of incarceration and release without addressing his real rehabilitation needs;233 (6) Motel type TA accommodation was not ideal for people with complex support needs and stable supported accommodation such as that provided by TSA and ERS and organisations such as the CRC are urgently needed to meet demand noting that 50% of people in prison have complex support needs;234 (7) The findings in relation to Jazzy were consistent with Recommendations 99 and 102 of the ICE Inquiry regarding the need for dedicated case management, safe and stable housing, primary and mental health services and drug treatment services on a health needs basis;235 (8) The appropriateness of LSR-I assessments for indigenous peoples and those with cognitive impairment was questionable as they are a one size fits all approach, noting that the assessments conducted on Jazzy over the course of his life did not result in the provision of a serious rehabilitation program;236 (9) Lack of services in regional areas would ideally be overcome by having the equivalent of a CRC in each regional town.237
232 Professor Eileen Baldry, Transcript, 16 November 2023, p35, 39.
233 Professor Eileen Baldry, Transcript, 16 November 2023, p44.
234 Professor Eileen Baldry, Transcript, 16 November 2023, 31, p47.
235 Professor Eileen Baldry, Transcript, 16 November 2023, p48.
236 Professor Eileen Baldry, Transcript, 16 November 2023, p37.
237 Professor Eileen Baldry, Transcript, 16 November 2023, p39, 50-51.
examining possible recommendations in this matter.
Evidence as to the state of
This was coupled with the fact that Jazzy had previously relapsed and offended whilst residing at in the context of substance abuse. Further, Jazzy was living alone and lacked pro-social supports and access to psychologists or general practitioners in the Raymond Terrace area. Jazzy’s family submitted that was unsuitable for Jazzy as substance abuse was a high-risk factor for him reoffending.
Ms Anderson, who was a senior practitioner of Port Stephens Family and Neighbourhood Services gave evidence that was affected by matters of hygiene and cleanliness, as well as high drug use, violence and intimidation and the presence of sex offenders.238 Ms Anderson said she was in constant contact with Hume Housing about the state of and Hume was in constant contact with .239
Mr McCarter gave evidence that Jazzy did not raise any concerns about the conditions at and if he had done so Mr McCarter would have reflected his concerns in the case notes.240 Mr McCarter was unaware of whether any complaints had been made by MCC to the Department of Housing regarding .241 Nor was the manager of MCC, Ms Lane.242 Mr McCarter gave evidence that he would steer clients away from if there were other accommodation options available for “exactly the same” reasons as those stated by Ms Anderson.243 The problem was the lack of alternative accommodation.
The manager of gave evidence denying the characterisation of the state of alleged by Ms Anderson. His evidence was that there had been occasions when issues as to the state of the premises had arisen, but they were dealt with promptly.244 If behaviour indicative of drug use or violence was witnessed, notified Hume Housing and where relevant, the Maitland Police Station. In those circumstances the person’s 238 Kylee Anderson, Transcript, 6 September 2023, p74.
239 Kylee Anderson, Transcript, 6 September 2023, p75.
240 Morgan McCarter, Transcript, 7 September 2023, p34.
241 Morgan McCarter, Transcript, 7 September 2023, p36.
242 Louise Lane, Transcript, 7 September 2023, p57.
243 Morgan McCarter, Transcript, 7 September 2023, p31.
244 Transcript, 16 November 2023, p4-6.
I note that in fairness, were given an opportunity to make final submissions on this issue, but nothing was forthcoming.
In weighing up this evidence I make the following findings. I accept the evidence of Ms Anderson from PSFNS about the dire state of around the time of Jazzy’s death. She gave her account in a straightforward manner with no evidence of exaggeration. Her account was effectively supported by Mr McCarter who told the court he would steer clients away from for the same reasons, if there was something else available.253 The picture they gave was of a place wholly unsuitable for providing adequate support for someone in Jazzy’s situation.
Jazzy’s family had submitted that PSFNS would have been unlikely to refer him there if were not an official TA provider. I accept that the TA registration gave some status, but the fact remains that PSFNS did assist Jazzy to stay there, well knowing the problems at that location. The referral was made simply because there was nothing else to offer in the local area and this is one of the tragedies of the whole situation.
The issues
This Inquest sought to focus on the manner of Jazzy’s death by a consideration of the following matters set out in the Issues List.
Was the management of Mr Gibbs relocation to Raymond Terrace reasonable and appropriate (including with reference to relevant Housing and Community Corrections Policies and Procedures at the time) including:
(i) Assessment of risks relating to the move; (ii) Assessment of prosocial supports relating to the move; (iii) Assessment of appropriateness of residence (including what accommodation was available and how such accommodation is funded); (iv) Assessment of the use of electronic monitoring during the period immediately after relocation;
(v) Arrangement of protective factors prior to move such as GP and psychologist; (vi) Engagement with family as to the appropriateness of the move;
was reasonable and appropriate in the context of the lack of adequate resourcing of CCOs and the lack of wrap-around services like CRC for complex support needs parolees.
I accept that once Jazzy informed his CC officer that he was moving, that officer had little or nothing to offer him by way of supported accommodation. Further I understand the impulse to keep him engaged in some sort of supervision or at least contact by transferring him to the MCC once Jazzy had gone ahead and secured his own accommodation by contacting a service that had known previously.
Counsel assisting submitted that the risks that Jazzy presented, in terms of re-offending remained high whether he was in the Burwood or in the Raymond Terrace area. His LSRI rating upon release from custody was the highest possible rating with the highest possible level of supervision and could not be further upgraded to address any increased risks resulting from relocation. Nor did CC policy allow for the refusal of transfer by a client. The focus of the CCOs was to facilitate supervision at any location rather than lose contact with a client.
The arrangement of protective factors such as contact with a GP and psychologist prior to the move was not something required by CC policy. Indeed, policy directed that finalisation of case plans prior to transfer, whilst ideal was not necessary and was not an appropriate reason to refuse transfer. Jazzy had a GP and psychologist arranged in the Burwood area including a MHCP which he told CCOs he was in the process of re-arranging in the Newcastle/Raymond Terrace area. Whilst MCC and PSFNS (accepting that the latter was unable to mandate attendance) could have assisted Jazzy with engagement with services once he had moved to Raymond Terrace, unfortunately Jazzy was not substantially engaged with either service prior to his death to facilitate this.
I accept that there is no criticism that can be properly directed to CC Officers in relation to the choice of as Jazzy’s accommodation. There was a complete lack of appropriate accommodation in the area. While was an approved TA provider, Jazzy was not there pursuant to the TA program at the time of his death. In fact he had been referred to a possibility of TA in the Burwood area, which he did not pursue. Ms Anderson told the court that while she had assisted him, Jazzy was there as “a permanent weekly rental” and was self funding his accommodation. This is supported by which produced a letter indicating that Jazzy was renting on a weekly basis.254 254 See Vol 7, Tab 24, Statement of David Plowright, Annexure D.
The court was informed that Jazzy had stayed at previously. The exact circumstances of Jazzy’s previous stay at in 2020 were not fully reviewed but it appears that he was initially at least housed as a TA client after Link2Home made a referral to the Port Stephens Family and Neighbourhood (PSFANS) specialist homelessness team.255 The evidence suggests that he was accepted back to in 2021 due to his having been previously known to the motel and having been referred as a housing client previously via Link2home.
This second stay at was as a result of a self-referral to PSFANS and was not pursuant to any suggestion or direction by a CC officer.
Motels are not suitable accommodation for housing supervised parolees with significant needs but are unfortunately used extensively across NSW due to a lack of social housing and supported accommodation. This results in untrained providers such as operating as facilities for persons with complex supports needs like Jazzy. The lack of suitable supported TA providers in the Raymond Terrace area remains an issue of very significant concern.
The assessment of pro-social supports relating to the move was complicated, as Jazzy had deteriorated, relapsed and re-offended at both relevant locations in the past but also had some pro-social support in both places. I accept both options had pros and cons which had been considered by BCC prior to the move. This complicated situation informed Mr Plowright’s decision not to communicate with Jazzy’s mother prior to the move as he was concerned about escalating Jazzy’s distress which he thought had the potential to result in offending and/or harm to persons.
I accept counsel assisting’s submission that the evidence in the inquest was clear that electronic monitoring was not appropriate in Jazzy’s circumstances. I accept the focus of CC was on preventing re-offending and ensuring community safety, neither of which would have been assisted in Jazzy’s case by the use of electronic monitoring. Electronic monitoring would not have detected a drug relapse or mental health deterioration.
Jazzy’s family submitted that Jazzy’s relocation to Raymond Terrace, in particular to , was not reasonable or appropriate. Jazzy’s family raised concerns that Mr Plowright did not adequately assess the risks involved in Jazzy relocating to Raymond Terrace, including adequately considering his pro-social supports, the lack of general practitioners and psychologists available and the unsuitable nature of the accommodation. Further, they raised concerns that Mr Plowright did not speak to or about this relocation 255 Vol 7, Tab 23, Statement of Kylee Anderson and file notes.
nor did he undertake a formal assessment as to the appropriateness of Jazzy. In circumstances where Jazzy was vulnerable and at the highest risk of reoffending, Jazzy’s family submitted that home remained the more appropriate location for Jazzy.
Counsel for the Commissioner of CSNSW submitted that the management of Jazzy’s relocation to Raymond Terrace was reasonable and in accordance with Community Corrections policies. It was submitted that Mr Plowright appropriately considered the risk of Jazzy’s relocation, including considering the pro-social supports at Burwood and Raymond Terrace, and developed a clear plan for Jazzy’s relocation with the support of Ms Anderson of PSFNS. Further, Mr Plowright sought to facilitate Jazzy’s engagement with Community Corrections rather than refusing a transfer which may have led to disengagement and an increased risk of reoffending. Although was recognised to be an “imperfect situation”, it was submitted that this was the only option for people who are homeless or transient in that area until other opportunities arose.
I have no trouble accepting the family’s submission that the accommodation was wholly unsuitable for Jazzy. However, I do not see that Mr Plowright had many available options when Jazzy appeared determined to leave his mother’s house. I understand the impulse to encourage Jazzy to remain in contact with a CC officer, even if that officer was in another area. I agree with the submission of CSNSW that had a transfer been refused, it is most likely Jazzy would have cut all contact and moved to anyway. Jazzy found that accommodation himself, it does not appear to have been suggested or supported by any CC Officer. The problem is not so much whether or not was suitable – it clearly was not, what Mr Plowright had to grapple with was how to keep Jazzy engaged and how to encourage him to at least remain open to supervision. I note that CC policy did not support Mr Plowright refusing the move.
At the conclusion of the evidence I was not critical of the individual officer, in my view he was faced with a very difficult situation when Jazzy decided to move and his actions were in all the circumstances reasonable given the constraints he was working under.
Was the management of Mr Gibbs once he had relocated to Raymond Terrace reasonable and appropriate (including with reference to relevant Housing and Community Corrections Policies and Procedures at the time) including:
(i) Provision of assistance in arranging GP and psychologist; (ii) Administration of drug testing; (iii) Direction regarding abstinence once relapse was reported and whether any
assistance provided in developing strategies or connecting to drug and alcohol counselling; (iv) Maintenance of supervision once relapse reported and contact lapsed;
(v) Engagement with family as to concerns about Mr Gibbs relapse; (vi) Extent of supervision provided by accommodation;
Counsel assisting submitted that the management of Jazzy once he had relocated to Raymond Terrace was reasonable and appropriate in the context of the lack of adequate resourcing of CCOs and the lack of available wrap-around services like CRC for complex support needs parolees.
Professor Baldry noted that MCC could have done more to substantiate that Jazzy had arranged a GP and psychologist, however she accepted the difficulties arising from under resourcing and the inability of a service like CC to meet the needs of complex clients like Jazzy. Whilst MCC and PSFNS could have assisted Jazzy in trying to find appropriate services, unfortunately Jazzy was not substantially engaged with either service prior to his death. PSFNS also had the limitation of not being a mandated service and so it could only assist Jazzy if he requested such assistance and then chose to attend.
Whilst Jazzy might have been drug tested by MCC when he disclosed a relapse, the CC policy did not dictate that drug testing occur, particularly in the context of a freely given admission when the result was unlikely to change the decision of the CCO as to how to proceed. The evidence was clear that parolees would not be breached for one disclosure of relapse or indeed a single positive drug test. The focus of CC was on supporting the parolee in the community to remain drug free so that they could remain crime free, and there was an acceptance that this may take some time. The process involves building rapport, finding appropriate drug treatment services and only moving to a parole breach as the last resort. The court was informed that this is an approach that is endorsed by the State Parole Authority. It appears appropriate and generally in line with relevant harm reduction principles. The breach of Jazzy’s parole on the basis of a single disclosure of drug use would likely have resulted in the SPA rejecting the breach report and directing CC to continue to manage him in the community.
In any event, the return of a parolee to custody to serve the remainder of their sentence would only result in a later release to the community without any parole supervision whatsoever. The decision of what to do about a relapse should be determined by the designated CCO as a matter of practice and as Jazzy had attended on a date that he was
not booked to attend, he had been seen by a non-designated CCO Ms Davies, who would not, as a matter of practice, decide how to deal with the relapse. Jazzy’s designated CCO Mr McCarter, upon seeing the report of drug use and becoming aware of Jazzy’s nonattendance at his next appointment attended to follow up what was happening for Jazzy. This was appropriate. Unfortunately, Jazzy was not present and no further contact was able to be made prior to Jazzy’s death.
Professor Baldry noted that what was actually required was a civil society health focussed approach, rather than criminal justice supervision which is focussed on managing community safety by addressing the risk of re-offending.
The level of supervision provided by was minimal or non-existent, The Manager received no training as a TA provider. If behaviour indicative of drug use or violence was witnessed the manager stated they notified Hume Housing and where relevant Maitland Police Station and the person’s accommodation would not be extended beyond 21 days. Additionally, a full-time security officer was on-site and the police drove through the motel carpark twice daily. I accept it is unrealistic to expect any motel managers to act as a social worker or to put their customers ahead of their need to turn a profit. This is the problem inherent in a system which outsources care and does not provide adequate social and supported housing.
Counsel for Jazzy’s family submitted that Jazzy was not appropriately supervised by Maitland Community Corrections. Upon Jazzy’s relocation to Raymond Terrace, Jazzy’s family are of the view that MCC should have immediately obtained support from a general practitioner and a psychologist for Jazzy considering his known mental health issues.
Jazzy’s family also raised concerns with Jazzy not being seen by his designated Community Corrections Officer, Mr McCarter, but rather by two other officers. Regarding Jazzy breaching his parole conditions, Jazzy’s family were concerned that Maitland Community Corrections did not drug test him, direct him to seek medical or mental health treatment, did not increase his supervision nor did they inform the family of these issues. Jazzy’s family submitted that Maitland Community Corrections should have intervened at this time due to Jazzy’s vulnerability and high-risk status, or at the very least they could have altered his supervision as opposed to ‘giving him time.’
Counsel for CS submitted that the management of Jazzy’s return to Raymond Terrace was both reasonable and in accordance with policy. Between 7 April 2021 and 7 May 2021 officers from MCC made numerous attempts to contact Jazzy. Jazzy’s attendance at MCC was irregular, but the court heard that his designated officer Mr McCarter left messages for Jazzy on 15 April 2021 and again on 20 April 2021. On 23 April 2021 when Jazzy had still not been in contact Mr McCarter attended to find him. When they finally spoke on 28 April 2021, Jazzy was directed to attend on 3 May 2021. Tragically on that day Mr McCarter was informed by that Jazzy was in John Hunter Hospital after an “ice binge”.
Mr McCarter gave evidence before me and impressed this court as a dedicated professional. I am not critical of his actions. However, the lack of resourcing, poor accommodation in which Jazzy was living and the shortage of support available in the community clearly impacted on the supervision provided.
Counsel assisting submitted that the management of Jazzy was reasonable and appropriate in the context of the lack of adequate resourcing of CCOs and the lack of wraparound services like CRC for complex support needs parolees.
Counsel for the Commissioner of CSNSW submitted that the overall management of Jazzy by Community Corrections was reasonable and in accordance with Community Corrections policies and procedures and the Service Delivery Standards according to Jazzy’s ‘tier 3/high risk rating.’ Counsel recognised limitations to resourcing, external service providers and COVID-19 restrictions which impacted on Jazzy’s supervision and welcomed further funding for external and wrap-around service providers that play an important role in the supervision and support of offenders in the community.
Counsel for Jazzy’s family submitted that the management of Jazzy by Community Corrections was not appropriate considering his risk factors and vulnerable status. Jazzy’s family raised concerns regarding Jazzy being able to transfer to TA accommodation which was not assessed with reference to Jazzy, the lack of provision of mental health and addiction support for Jazzy once he relocated and the lack of consequences imposed on Jazzy or change in supervision style when Jazzy breached his parole conditions. Jazzy’s family submitted that Jazzy should have remained with and his stepfather where he was being meaningfully supervised by Community Corrections.
While I am very sympathetic to the concerns of Jazzy’s family, I see the issue as one not so much of poor CC supervision, as poor overall support. I am convinced that what Jazzy needed was a dedicated support worker from outside Community Corrections, rather than a CCO who demanded better compliance or undertook hasty breach action.
The need for recommendations pursuant to s 82 Coroners Act
Section 82 of the Coroners Act 2009 confers on a coroner the power to make recommendations that he or she may consider necessary or desirable in relation to any matter connected with the death with which the inquest is concerned. It is essential that a coroner keeps in mind the limited nature of the evidence that is presented and focuses on the specific lessons that may be learnt from the circumstances of each death.
Counsel assisting put forward a number of draft recommendations for consideration which I will now consider in turn.
To the Commissioner of Corrective Services NSW (1) To Advocate for an increase in both funding and the roll out of wrap-around services for parolees with complex needs including case managers such as those provided by the Community Restorative Centre consistent with recommendations of the Special Inquiry into the drug ‘Ice”.
Counsel for CSNSW submitted that CSNSW support the intent of the proposed recommendation to facilitate effective post release support for parolees with complex needs. CSNSW agreed that the availability of wrap-around services, such as the Community Restorative Centre, play an important role in the management of parolees, particularly those who face complex and multi-dimensional needs. CSNSW acknowledge that the demand for such services outweighs the supply due to limited funding.
CSNSW drew the court’s attention to a new program, announced in November 2023 - the Post Custodial Support (PCS) program which has now been funded as part of the NSW Government’s response to The Ice Inquiry. The PCS will provide intensive and comprehensive treatment and support for people leaving custody who have a risk of harmful drug and alcohol use. As I have stated earlier such programs need urgent implementation.
I accept CSNSW’s submission that the recommendation can properly be limited to recommendations 99 and 102 of the Ice Inquiry, in keeping with the evidence and issues raised at this inquest. I intend to make the recommendation in those terms.
(2) To ensure adequate training of Community Corrections Officers in mental health and complex support needs clients.
supported by Jazzy’s family who identified the gaps in the assistance Jazzy received for his mental health issues.
An alternative formulation was suggested given that while the issue was raised in evidence, the court did not have comprehensive information about current training. I accept that submission and intend to make the recommendation in the form suggested.
(3) To Review Community Corrections Policies and Practices to ensure continuity of service to complex support needs parolees by their designated Community Corrections Officer
I note that CSWNSW accept this recommendation and express a willingness to review the relevant policies.
Jazzy’s family also supported this recommendation, however, I note they also seek a review of policies relating to the transfer of parolees, particularly those with complex needs, the completion of Risk Mitigation Plans for transfers and breaches of parole conditions and the supervision of community corrections officers. These are important issues but in my view, given the limited evidence in this inquest such extensive reviews may be beyond scope.
(4) To negotiate uniform Memorandums of Understanding and/or Service Agreements as between government organisations including Department of Community Corrections, Department of Communities and Justice and non-government organisations including Port Stephens Family and Neighbourhood Service and Temporary Accommodation providers including
CSWNW agreed with the intent of this recommendation calling, as it does for stronger collaboration and cooperation between various organisations and entities. However CSNSW submitted that the suggested proposal “would not be practical in light of the evolving needs of parolees, changing availabilities of non-government services and consent requirements to share personal information”.
An alternative was suggested which would serve to assist in clarifying roles and strengthening understanding between relevant agencies.
Having considered the issues I intend to make the recommendation suggested by CSNSW.
To the Secretary, Department of Communities and Justice
recommendations were best directed to particular officers within the Department, that is to the Director of Housing Statewide Services and the Executive Director of Housing, Homelessness, Disability and Seniors. While this may be correct, I am of the view that the recommendations may be best considered by the Departmental head and then re-directed.
(5) To consider a long term strategy to move away from heavy reliance on motel accommodation for parolees at risk of homelessness.
While he had a supportive mother, for whatever reason he was not prepared to stay with her. In my view he was effectively homeless and in need of an emergency bed. He fell back on an option he had previously been referred to through Link2home, the motel accommodation provided by
He may have been self-referred on this occasion but it is worth noting that his parole officer apparently had no supported accommodation option to suggest.
I accept the submissions of counsel for Housing Statewide Services, (DCJ) that in the first instance DCJ will, as a matter of course, seek to refer a client experiencing or at risk of experiencing homelessness to a SHS if support is indicated. It was submitted that only if nothing is available will simple TA assistance be offered. While there are some supported TA (STA) providers which offer support as well as accommodation, most TA is provided by commercial operators, like motels or hotels, paid on a fee for service basis. I understand the submission that the emergency nature of some requests will sometimes necessitate the use of motels and hotels and for that reason I accept that it may well be an integral part of the overall system, particularly in rural NSW. Nevertheless I remain extremely concerned about our over-reliance on these commercial providers.
While counsel for DCJ stated that motels are only used as “temporary or crisis accommodation” or as “a stepping stone”. I do not think this is the case. The statistics before me suggest otherwise.
In my view there is a clear need to expand the available options for those leaving custody.
Some good programs are already in place, but they need to be rolled out more widely if they are to create effective change and for that reason I have decided to expand the recommendation to include counsel for DCJ’s suggestion about the need to specifically advocate for increased funding of SHS.
(6) To negotiate uniform Memorandums of Understanding and/or Service Agreements
as between government organisations including Department of Community Corrections, Department of Communities and Justice and non-government organisations including Port Stephens Family and Neighbourhood Service and Temporary Accommodation providers including
I note that counsel for Housing Statewide Services, DCJ submitted that DCJ Housing agreed with “the intent of the recommendation to promote collaboration between DCJ, CSNSW and non-government organisations such as PSFANS and TA providers.” However, given Community Corrections which is a division of CSNSW and DCJ Housing both fall under the Department of Communities and Justice a MOU is not the appropriate vehicle to improve collaboration.
I note that there was evidence before me about a local inter-agency meeting in the Raymond Terrace area which had to some degree improved relationships and it may be that local arrangements such as this are the most crucial to pursue.
Counsel for Housing Statewide Services proposed two alternate recommendations aimed as a “viable alternative to negotiating Memorandums of Understanding and Service Agreements.” I accept that the proposed recommendations aim to encourage the continuation of collaboration between DCJ Housing and CSNSW and the provision of information to confirm the service expectations and processes in place to ensure the ongoing suitability of TA providers. I intend to make the recommendations suggested.
Findings
Manner of death
Recommendations pursuant to section 82 Coroners Act 2009
(2) Review training on mental health and complex support needs to identify whether it meets the needs of Community Corrections Officers.
(3) To Review Community Corrections Policies and Practices to ensure continuity of service to complex support needs parolees by their designated Community Corrections Officer.
(4) To consider the publication of an information sheet on the role of Corrective Services NSW, the aims of community based supervision and the ways in which non-government organisations can support the management of offenders in the community.
To the Secretary of the Department of Communities and Justice – for the attention of Director of Housing Statewide Services and the Executive Director of Housing, Homelessness, Disability and Seniors (5) To consider a long term strategy to move away from heavy reliance on motel accommodation for parolees at risk of homelessness, which must involve strategies such as increased funding for Specialist Homelessness Services that can provide wrap-around services.
(6) To Continue the refinement of procedures, as appropriate, requiring annual inspections of Temporary Accommodation providers to ensure ongoing suitability.
(7) To continue collaboration with Corrective Services NSW to provide housing assistance for inmates and parolees who are at risk of homelessness, including the development of a Housing Portal on inmate tablets which provides information about housing services, products and assistance prior to release from custody.
(8) To consider the development of an information pack to be provided to Temporary Accommodation providers, outlining annual inspections that are to be completed by DCJ
Housing offices or Social Housing Management Transfer location community housing providers (SHMT CHPs) as well as the contact details for any complaints raised by the TA provider or TA guest.
Conclusion
The problems Jazzy faced require a different approach to that which emerged in the evidence. Jazzy required intensive wrap-around support for his complex needs and that care was best delivered separately to the CC supervision regime he was under. While this kind of wrap-around support doesn’t exist or is rare, I can understand Jazzy’s family seeing the issue as a failure of CC supervision. Unfortunately the kind of support CC officers are able to provide was never going to work for Jazzy, no matter how well meaning or competent individual officers may have been.
I offer my sincere thanks to counsel assisting Rebekah Rodger, and her instructing solicitors Sarah Crellin and Amy Halliwell for their very great assistance in this matter. I also note the cooperative manner in which parties approached these proceedings.
Finally, once again I offer my sincere condolences to Jazzy’s family. His life was cut short in circumstances where our community had failed him over many years. His final release from custody was no different. Once he left his mother’s home, he had no appropriate accommodation and lacked support. He returned to a motel where he had a history of drug use and within weeks he was dead. I echo Professor Baldry’s sentiments in saying much of what needs to be done is already clear and has been the subject of extensive public inquiry.
Steps such as fully implementing the recommendations of the Ice Inquiry would certainly be a step in the right direction.
Magistrate Harriet Grahame Deputy State Coroner, NSW State Coroner’s Court, Lidcombe 20 February 2024
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