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The deceased was in the psychiatric unit at Long Bay Prison.He approached a nurse on 25 July 1989 at 2.30pm and stated he was feeling ill.Social Justice Commissioner Comment The clarity of these coronial findings is limited by an apparent lack of preparation.This is creates difficulties for both families and the institutions involved.

Summing Up The deceased was detained at a juvenile institution, Endeavour House.

She gave him advice as to the illness and provided him with medication.

He later approached another nurse and said he wanted to return to his cell.

He was an inmate at the Silverwater Prison Complex.

On Saturday 21 October 1989 at about 8pm the deceased complained of a headache and earache which had apparently started the day before.

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