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.