Inquest into the deaths of Nicholas KARAYIANNIS andTien TRAN Decision of Deputy State Coroner Dillon on 13 October 2015 CATCHWORDS CORONERS, cause and manner of death, deaths in custody, Homicide/suicide of cellmates, Whether mental health assessment reasonable, Whether prisoners safe at night, Whether remand prisoners sufficiently informed of self-harm protocols, whether"culture of silence" among prisoners jeopardising prisoner safety, whether "knock-up" alarm system sufficient protection for prisoner.

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