监狱系统失灵导致一名患有精神病的囚犯死于可预防的死亡,他得不到水。 Jail systemic failures led to the preventable death of a mentally ill inmate who was denied water.

Simon Cartwright, 41岁,患有严重心理健康问题,2021年在银水改造院因化粪池休克而死亡。 Simon Cartwright, a 41-year-old man with severe mental health issues, died from septic shock at Silverwater Correctional Complex in 2021. 州立副验尸官Erin Kennedy发现他的死亡是可以预防的,原因是系统失灵,包括将他转移到精神病院的延误。 Deputy state coroner Erin Kennedy found his death was preventable, due to systemic failures including a delay in transferring him to a mental health facility. 监狱工作人员在洪水发生后关掉了牢房的水,而他要求供水的呼声却被忽视了。 Prison staff turned off the water in his cell after flooding, and his pleas for water were ignored. Kennedy强调了在承认他日益恶化的状况方面的失败,并提出了改进监测和精神健康服务的建议。 Kennedy highlighted failures in recognizing his worsening condition and made recommendations for improved monitoring and mental health services.