The hanging deaths of prisoners supposedly being held under close observation in cells specifically designed to prevent self harm continues to raise doubts about supervision and monitoring practices in NSW prisons.

Custodial officers did not find the body of Manoa Tupou — a prisoner identified as being “at risk of self harm” — for one hour and 44 minutes after his death, despite the fact Tupou was supposed to be on 15-minute observations in a “safe cell” at the Silverwater prison complex. A safe cell (or observation cell), according to a Department of Corrective Services spokesperson, is specifically 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”.

Deputy state coroner Paul MacMahon, who investigated Tupou’s death, found the Department of Corrective Services had failed to fulfil its responsibilities and its actions “were a significant contributing factor” to the death. “It is abundantly clear that he was neither monitored in accordance with the plan developed nor was the cell that he was placed in safe,” MacMahon wrote in his findings.

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He described the department’s procedures for CCTV observation as “random”, noting in his findings that “there was no certainty that Mr Tupou’s cell was monitored during any specified period or at all”. He found that although several officers could have monitored the cell, no officer was specifically designated the task and several were distracted at the time, including “[o]ne officer, who … was playing table tennis with an off-duty officer during the period during which Mr Tupou took his life”.

Although stopping short of concluding negligence on the part of any officers, MacMahon was nonetheless scathing in his assessment:  “The evidence available does not allow me to conclude that the departmental officers involved in the supervision of Mr Tupou on 28 November 2007 did not treat the issue of providing proper care … with appropriate seriousness, however the actions and inactions of the officers involved are certainly suggestive of such an attitude.”

The 2009 inquest also revealed that the light fitting from which Tupou hanged himself had already been identified by Corrective Services officers as a hanging point on two previous occasions — in February 2007, just nine months before Tupou’s death, as well as in August 2006. The fitting should have been removed or screened, as required by Recommendations 165 of the Royal Commission into Aboriginal Deaths in Custody. It was not, and on November 28, 2007 Tupou — a 26-year-old remand prisoner with schizophrenia, drug-induced psychosis and a history of psychiatric admissions and self harm — was found hanging from that light fitting, four days after being taken into custody.

At the time of his death, Tupou was the second inmate in three years to die while supposedly under close watch. Less than two years earlier, deputy state coroner Carl Milovanovich examined the death of Aboriginal remand prisoner Wendy Hancock, who attempted suicide while purportedly on 10-minute observations. The 38-year-old died in hospital from the resulting brain injuries.

Hancock had a long history of health and mental health issues, including depression and substance abuse disorders. She had made three known suicide attempts and “was the victim of a serious s-xual assault shortly before being taken into custody”, according to the findings of the 2006 inquest into her death. She died on October 3, 2004, six days after having entered the care of Corrective Services.

Hancock was identified of being at risk of self harm when admitted to Mulawa Reception and Remand Centre for Women (now Silverwater Women’s Correctional Centre). Her “risk management plan” recommended she be kept in a camera cell, with 10-minute observations. Cell 15, where Hancock was housed, was equipped with video surveillance, allowing for round-the-clock observation.

The inquest into Hancock’s death found that correctional staff failed to monitor her cell for at least 22 minutes. According to the investigating coroner, Hancock’s behaviour during that time “would have raised immediate concern” had officers been paying attention.

The surveillance video from the day of her suicide attempt shows Hancock receiving a cigarette at 3.03pm. At 3.05pm, she removes her underwear; at 3:15pm, she is seen throwing milk over the camera lens, presumably to distort the picture. Three minutes later, the video shows Hancock making a noose from her underwear and placing it around her neck.

A further seven minutes pass before a correctional officer notices Hancock “sitting” near the grilled door of her cell and orders a cell check.

Again, poor management was among the factors blamed for the death. “The failings of the staff on duty were compounded by the lack of clear delegation of duties, no apparent management structure and no clear and concise statement of responsibilities,” wrote deputy state coroner Carl Milovanovich in his findings.

He noted that the “Morse Watchman” — a device for recording and downloading observation data — was not used for some nine hours before Hancock was found hanging from the cell door.

*This is the fifth in a series of case studies and investigative reports into prison deaths


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Peter Fray
Peter Fray
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