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The Coroner also expressed concern at the delay in personal notification of the deceased's death to the family.The family first heard of the death through the media.He criticised officers for allowing the deceased's application for transfer to the adult prison to be processed without counselling or consultation with the family.

The doctor determined that he should be sent to Auburn District Hospital.The deceased's request indicated that he was unable to perceive his own best interest and that he was under severe emotional strain.The Legal Service also submitted that the deceased's state of mind was affected by the suicide of a fellow detainee at Endeavour House and his incarceration at a security gaol.Social Justice Commissioner Comment The clarity of these coronial findings is limited by an apparent lack of preparation.