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flag Jail systemic failures led to the preventable death of a mentally ill inmate who was denied water.

flag Simon Cartwright, a 41-year-old man with severe mental health issues, died from septic shock at Silverwater Correctional Complex in 2021. flag 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. flag Prison staff turned off the water in his cell after flooding, and his pleas for water were ignored. flag Kennedy highlighted failures in recognizing his worsening condition and made recommendations for improved monitoring and mental health services.

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