One quarter of inmates who suicided in NSW prisons in the past nine years did so within days of having been assessed as no longer at risk of self harm or suicide, and suitable for release from emergency intervention protocols.

Figures compiled from a Crikey analysis of coroners’ findings into deaths in custody — part of a multipart investigation into the issue — reveal coroners criticised the conduct of prison or health agencies in 45 of the 57 cases of suicide investigated in the past nine years. In 42 cases the inmate had one or more psychiatric illnesses, 25 had a known history of self harm, and 16 had previously attempted suicide, some while in custody.

These findings continue to cast doubts — first raised more than 20 years ago, during the time of the Royal Commission into Aboriginal Deaths in Custody — on the usefulness of the Corrective Services and Justice Health protocols that govern how authorities deal with inmates considered to be at risk of self harm or suicide.

Invest in the journalism that makes a difference.

EOFY Sale. A year for just $99.


They also highlight serious inadequacies in the ongoing management of the mentally ill, particularly in the period immediately following release from “risk intervention team” (RIT) protocol. This mandatory emergency protocol, which officers initiate when a prisoner is suspected of being at risk of self harm, requires the inmate to be housed in a “safe cell” or “observation cell”. A Corrective Services spokesperson described observation cells to Crikey: “[They’re] designed to minimise the opportunities of self harm, so therefore it’s got no hanging points, they’ve got special blankets, it has camera observation and nothing sharp or unscrewable.”

Commissioner Elliott Johnston questioned the use of such cells in the Royal Commission’s final report, delivered in 1991. “[T]he use of observation or isolation cells is not universally accepted as an appropriate response to persons identified as at risk,” he wrote, noting, “that research has generally shown that suicide is more common in segregation or isolation cells.”

Sixteen of the Royal Commission’s 46 recommendations on custodial health and safety make specific reference to the identification and management of the mentally ill or “at risk”; nine refer specifically to management within the prison environment.

Coroners have continued to support these recommendations at numerous inquests, including the landmark inquest into the death of Aboriginal inmate Eddie Russell in 1999. Then senior deputy-state coroner Jacqueline Milledge made 26 recommendations — a number unsurpassed in any inquest since — in her findings, delivered in 2002. Eleven of these specifically addressed the assessment, placement, and ongoing management of mentally ill and “at risk” inmates.

Milledge was deeply skeptical about management procedures for “at risk” versus “normal” inmates. “If ‘at risk’, the inmate is housed in a safe cell and observed. When the ‘risk’ has resolved, the inmate is returned to the general prison population,” she wrote in her inquest findings. “As a lay person, I find it extremely difficult to comprehend how an inmate can be suicidal and considered ‘at risk’ one day and then return to ‘normal’ within 48 hours.”

Much of the risk assessment, Milledge noted, relies on two factors: first, the absence of attempts to self harm while in the safe cell, and secondly, the inmate’s retraction of threats to self harm. She again questioned the wisdom of the department’s approach: “Given the sterile environment of [the safe cell], no attempt to self-harm is not surprising.”

Other coroners have raised similar doubts about the retraction or denial of thoughts of self harm. In 2007, deputy state coroner Milovanovich warned prison and health authorities that: “Sight should never be lost of the fact that in many cases prisoners will not divulge any suicidal ideation as they are aware that it will result in … being placed in a safe cell and being under constant observation. This is even more prevalent with prisoners who have been through and are familiar with the prison system.”

Yet despite repeated and urgent calls for vigilance, the mentally ill continue to die in prisons at a phenomenal rate.

Catriona McComish, a former senior assistant commissioner at Corrective Services NSW who served for five years as Director of Psychological Services, says safe cells symbolise the continued prioritisation of risk containment over rehabilitation in the prison environment.

“If someone is regarded as significantly distressed and is either self harming or is psychotic or is assessed and at risk of suicide in a hospital setting or a clinical setting then you ensure that they stay with people, they’re calmed down, they’re calmed with medication and talk and company and assistance and support,” she told Crikey.

“Whereas in prison the kind of assessment would err — because of the inquiries that have been and because of the fear of the ramifications of death in custody … on the side of just containing the risk, which means containing the person. It is certainly not good for the longer term outcome and if you put someone who’s got a mental illness, who is actually at risk of suicide … in a safe cell [it] is going to make them much, much worse.”

Nicole Jess, a senior correctional officer with 23 years experience in the job, says although mental health resources — in terms of psychologists, psychiatrists and mental health nurses — in prisons have improved dramatically in the past 20 years, the lack of mental health training among custodial officers is still a problem.

“You don’t get trained [in mental health] but some of the time you’re doing the role of a psychologist when you’re working … and that’s a hard thing for prison officers to do sometimes because it’s not really what people thought their role would be when they first joined the job,” Jess said.

“You can do [mental health] courses but they’re optional … so you can actually have people who are working [in the mental health wings] permanently who haven’t had any mental health training.”

*This is the fourth in a series of case studies and investigative reports into prison deaths. Next week, how inadequate supervision practices failed to save suicidal prisoners.


Australia has spoken. We want more from the people in power and deserve a media that keeps them on their toes. And thank you, because it’s been made abundantly clear that at Crikey we’re on the right track.

We’ve pushed our journalism as far as we could go. And that’s only been possible with reader support. Thank you. And if you haven’t yet subscribed, this is your time to join tens of thousands of Crikey members to take the plunge.

Peter Fray
Peter Fray
SAVE 50%