The hanging death of Aboriginal inmate Larna Louise Ryan could have been avoided had prison and health authorities simply checked her medical and case history. There, according to the coroner who investigated her death, staff would have found a “plethora of information” warning that Ryan was a serious suicide risk.  Yet despite years of recommendations, policies and procedures urging staff to check prisoner files when conducting assessments, the documents lay untouched until far too late.

Coroners have uncovered inadequate assessment and screening practices at more than 20 inquests into deaths in NSW prison custody in the past nine years, as Crikey began to detail last week as part of a special investigation. Formal recommendations urging government agencies to improve assessment procedures and enforce strict screening protocols were made in 2002, 2003, 2004 and 2006. Yet despite these recommendations, inadequate screening and assessment practices  again were identified as contributing factors in two deaths in 2009.

Ryan died at Bathurst Correctional Centre in March 2005. Her last days alive paint a picture of bureaucratic incompetence, at best, or negligence, at worst. No stranger to the prison system, Ryan had a long history of self harm, including two previous suicide attempts while in custody, and multiple psychiatric illnesses, including drug addiction and depression. According to department records examined at the 2007 inquest, Justice Health staff had triggered emergency protocols 24 times during her previous periods of incarceration, when Ryan was identified as being at risk of self harm or suicide.

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Refused bail after her arrest for dishonesty offences, Ryan repeatedly warned her family that she would not be able to handle being in prison and would kill herself before returning to custody. Ryan’s aunt, Tina Bonham, said at the inquest she relayed this information to Justice Health staff, but files contained no record of the conversation.

Five days later, Ryan was dead.

Deputy state coroner Carl Milovanovich found prison and health authorities had failed to identify the grave risk to Ryan’s safe custody.

“The death of Larna Ryan in my view could have been avoided … if it was determined, having regard to all the information that was available, that there was a risk of her self-harming,” Milanovich wrote in his findings. “[T]he question that must be asked is why did Correctional and Justice Health staff not access the plethora of information that was available in regard to Ms Ryan’s previous history.”

Authorities twice breached Recommendation 126 of the Royal Commission into Aboriginal Deaths in Custody, which states: “That in every case of a person being taken into custody … a screening form should be completed and a risk assessment made … [T]he screening form should be completed with care and thoroughness.” The inquest found no evidence that Corrective Services staff assessed Ryan on arrival at Bathurst jail, either when she was first remanded or when she returned after a later court appearance.

Records indicate that Ryan was assessed by Justice Health staff, but these assessments were incomplete as staff failed to “obtain a comprehensive medical history for the prisoner including medical records from a previous occasion of imprisonment”, as required by Recommendation 157. This failure became clear at inquest, when Justice Health presented the findings of its own investigation into the death, which revealed Ryan’s medical and case files did not arrive until after her death.

The absence of these files was a second breach of Recommendation 157, which also states: “That prisoner’s medical history files [should] accompany the prisoner on transfer to other institutions and upon re-admission.” Milovanovich was frank in his analysis: “I fail to see any reason in this day and age why medical records cannot be sent by courier — even over a weekend — from the Sydney record base to any place in NSW where an inmate is received.”

The Royal Commission was unequivocal about the importance of a prisoner’s medical and case history. In its final report, Commissioner Elliot Johnston wrote: “The adequate assessment of a prisoner is highly dependent upon the information available at the time of assessment … Ambiguous signs may take on a clearer significance if placed in the context of a history of medical or psychiatric illness. Access to a prisoner’s medical history records, both from the prison medical service and from outside health agencies would, therefore, be of potentially enormous benefit at the time of assessment.”

Milovanovich did not make formal recommendations at the inquest into Ryan’s death, noting that the issue of ensuring an inmate’s medical files were accessed “has already been subject to either formal recommendations or comment by coroners and there is now a standing direction that medical records must be accessed immediately”.

Yet 15 days after these findings were handed down, another inmate who had also previously attempted suicide and was known in the prison system as being “a high chronic risk of self harm” hanged himself at Long Bay Correctional Centre. In a disturbing echo of Ryan’s case, the inquest into his death revealed that his family, like Ryan’s, had also made efforts to warn Corrective Services and Justice Health staff that he was planning to kill himself.

Desmond Walmsley died 10 days after entering the mainstream prison, having never received any psychological assessment from Corrective Services or Justice Health staff.

Walmsley’s welfare officer admitted at the inquest that she did not read Walmsley’s “discharge summary” — a document summarising an inmate’s previous periods of incarceration — when assessing whether he was at risk of suicide, breaching Recommendation 157. Corrective Services’ internal guidelines on the use of discharge summary forms state: “The information is crucial to screening staff when receiving an inmate back into custody, for checking such matters as the inmate’s behaviour, medical issues, management alerts etc. Staff, Case Management Teams and the Classification Consultative Group also use the form to check that information is accurate and to obtain an overview of the inmate’s general interaction and behaviour during their past period in custody.”

Had Walmsley’s welfare officer checked his discharge summary during the assessment, she would have read the following: “Mr Walmsley is considered a high risk of self harm due to the following factors: Recent serious attempt to kill himself; charged with capital crime of murdering his partner; history of suicidal ideation; recent incarceration, on remand, and first time in custody; few social supports in community and custody.” The summary had been prepared following Walmsley’s discharge from the Acute Crisis Management Unit — a specialist unit for safe and humane crisis intervention at Long Bay Correctional Centre — eight days prior to the assessment.

In his findings, delivered in August 2009, deputy state coroner Paul MacMahon commented: “It would be anticipated that the early period of transition from the intense supervision of the ACMU to the mainstream prison would be likely to be the greatest time of need for an inmate who is at risk of self harm and as such Mr Walmsley ought to have been reviewed during that time.”

Corrective Services NSW and Justice Health were contacted for comment but did not return emails or phone calls.

*This is the second in a series of case studies and investigative reports into prison deaths. Next week, the warning signs before the 2007 hanging death of Aboriginal inmate Adam Douglas Shipley.