Part C - Profiles Analysis

It is totally unreasonable for police who catch the crooks to then be accountable for their welfare.

Western Australian Police Union Secretary,
after the death of an Aboriginal man at the East Perth Lockup, 1994¹
(profile 65WA)

Chapter 8 Custodial Conditions

Summary

8.1 The profiles indicate a growing awareness by custodial and medical staff of issues concerning the proper treatment of both Indigenous and non-Indigenous prisoners. However, implementation of the recommendations is uneven. Some recommendations have not been implemented in any jurisdiction.

8.2 In nine of the 61 investigated cases concerning deaths in institutional settings there was evidence that police, prison officers and medical staff were unaware of their duty of care to detainees. There was also a noted absence of internal disciplinary proceedings to deal with breaches of instructions relating to the care of people in custody. 8.3 De-briefing procedures have not been properly utilised to prevent future deaths in the same circumstances. Avoidable deaths occurred in almost identical circumstances in a number of cases. 8. 4 Deaths of Indigenous people in police cells and vans have decreased since the Royal Commission. However, all of the sixteen investigated deaths in police custody revealed numerous breaches of Royal Commission recommendations. 8.5 The circumstances of deaths in police cells and vans indicated that:

a. There was a lack of proper assessment procedures and little involvement of medical personnel, including Aboriginal Health Services.

b. There was often no protocol for dealing with intoxicated people, particularly in Queensland and Victoria.

c. Police officers were insufficiently trained to distinguish intoxication from other injuries. Persons who needed urgent medical help were frequently detained;

d. The observation of detainees was often irregular and infrequent; and

e. The Aboriginal Visitor Scheme does not appear to fully implemented.

8.6 The increase in the number of deaths in prisons calls for increased scrutiny of the operation and funding of prisons, particularly in relation to health services and general prison conditions.

8.7 The circumstances of deaths in prisons indicated that:

a. Health services in some prisons were well below community standards;

b. The provision of psychiatric services is a continuing problem in all jurisdictions;

c. In one third of the cases 'at risk' information concerning the deceased was not passed between medical and prison staff, or from police to prisons. It is extremely important that this situation is urgently remedied;

d. The rate of suicide in Queensland prisons was twice the national average. In eight of the nine of the investigated deaths there was no protocol for those at risk of self-harm. In other States protocols for self-harm were sometimes unsatisfactory or were not followed by staff;

e. Medical staff and prison officers were often not aware of cross-cultural health issues, particularly heart disease, and performance on the recruitment of Indigenous staff was poor;

f. Some jurisdictions have not fully implemented recommendation 156 through providing an assessment on the reception of prisoners by a medical practitioner. This was a contributing factor in a number of deaths; and

g. There was a lack of proper procedures for the exchange of medical information between external health services and prison staff.

8.8 Some delay or deficiency in attempting to resuscitate detainees was evident in 17 of the 61 cases investigated by the coroners. Problems were caused by inappropriate security procedures which delayed access to prisoners locked in cells, inadequate training and faulty resuscitation equipment. Despite all states and territories claiming implementation of recommendation 161 the failure to seek medical attention when doubts arose as to the medical condition of prisoners was a serious problem in the deaths under investigation.

8.9 Of the four Aboriginal people shot by police between May 1989 and May 1996, three were mentally ill and the fourth was a highly intoxicated 16 year old. None had firearms. Police firearms training was criticised as focussing on the 'criminal element' only, instead of contemplating people with mental disabilities. Guidelines for the use of restraint equipment were also found not to comply with Royal Commission recommendations.

8.10 There are indications that prisoners are still being charged with criminal offences or breaches of prison regulations in relation to suicide attempts.

8.11 Some of the cases provided information on recommendations concerning general prison conditions. Few prisons have employed Aboriginal Welfare Officers and implemented a transitional period to assist remandees or freshly sentenced prisoners in adjusting to prison life. In some prisons shared cell accommodation was not available.

Introduction

Improvement of custodial conditions is critical for all prisoners. Further, prisons are disproportionately comprised of people from disadvantaged backgrounds including those from different cultural and racial backgrounds and people with mental illness.

Significant progress has been made in improving custodial conditions since the Royal Commission found, 'glaring deficiencies in the standard of care afforded many of the deceased during... the period of incarceration.' Coronial inquests indicate an improvement in screening procedures, provision of physical and mental health services, training of police and prison officers and better cell conditions. However, implementation is still partial and varies significantly across Australia. The above statement of the Western Australian Police Union Secretary indicates the cultural and attitudinal changes have a significant way to go.

Recommendations concerning custodial conditions have been broken down into six sections. Section 1 concerns duty of care, disciplinary action and de-briefing procedures for police and prisons (R122-4). Section 2 addresses custodial health and safety of detainees in police custody (R125-49) while section 3 concerns custodial health and safety in prisons. Section 4 considers general custodial health and safety issues relevant to both police and prisons. Section 5 addresses recommendations concerning prisoner welfare (R168-87). Section 6 considers medical care outside prison and police cells as hospitals and non-prison doctors there were involved in the medical care of a number of the deceased. Recommendation 167 concerning juveniles is addressed in chapter 9.

The increase in the number of deaths in prison and the decline of deaths in police cells raises questions as to the interpretation of the recommendations. The Royal Commission provided more detailed recommendations on health and safety in police custody (R125-4). These recommendations should be used by Prison Medical Services in interpreting the briefer recommendations concerning prisons, ² particularly given the speedier transfer of detainees, as discussed in chapter 2. ³ However, for the purposes of this Report these recommendations will only be considered in deaths occurring in police custody.

1. Duty of Care, Discipline and De-briefing Procedure

Table 8.1 Duty of Care, Discipline and De-briefing Procedure

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Recommendation 122 - Recognition of the Duty of Care
That Governments ensure that:

1. Police Services, Corrective Services, and authorities in charge of juvenile centres recognize that they owe a legal duty of care to persons in their custody;
2. That the standing instructions to the officers of these authorities specify that each officer involved in the arrest, incarceration or supervision of a person in custody has a legal duty of care to that person, and may be held legally responsible for the death or injury of the person caused or contributed to by a breach of that duty; and
3. That these authorities ensure that such officers are aware of their responsibilities and trained appropriately to meet them, both on recruitment and during their service.

In at least ten cases it was clear that police and prison officers were unaware of their duty of care or the relevant instructions (27NSW, 39NSW, 62NSW, 67NSW, 14QLD, 21QLD, 25QLD, 53QLD, 1SA and 65WA).

New South Wales, Victoria, Western Australia and Northern Territory claimed implementation of this recommendation. The remaining jurisidctions claimed part implementation.

Six of the cases occurred in police cells. In all of the cases police officers were not aware of their instructions and in five of the cases coroners also recommended that instructions be revised. The cases demonstrate that recommendation 122c cannot be adequately implemented without an increase in the length and quality of police training.

In the death at Mornington Island Watch-house (21QLD) the Coroner held that there was a failure on the part of all individuals on duty during the incarceration of the deceased at the police watch-house to properly perform their custodial duty and responsibility. He found that the practice of driving past the watch-house and observing the cells by shining the headlights through the front screen mesh was improper and inadequate and not in accordance with General Instructions, and inspections of prisoners were infrequent and not in accordance with instructions. The Coroner also recommended that the General Instructions be revised to be consistent with Royal Commission recommendations.

In the death of a 34 year old man at Rockhampton Watch-house (25QLD) the Coroner found that in training police officers were simply shown a list of orders on a wall upon commencement at the police station. The Coroner found that the police officers were young and inexperienced and unaware of proper procedures. He recommended that the standing orders at Rockhampton Watch-house be totally revised and urgently updated and include the recommendations of the Royal Commission.

A similar finding was made in the case of the woman who died at Macquarie Fields Police Station (39NSW). The Coroner found that the police officers were young and inexperienced and unaware of the proper procedures for looking after detainees. The assessment form was incorrectly filled out and records of observation were not kept. The Coroner also found that Police Instructions were regularly breached in keeping sentenced prisoners in police cells.

In the death of a man in a police van in Brisbane (53NSW) the Coroner found that two police officers did not have sufficient, if any, knowledge of the contents of the Custody Manual. He also found that there was an inadequate system in place to ensure that all officers complied with the circulars and familiarised themselves with the contents of the Custody Manual.

In the case of the man who died at Ceduna Police Station (1SA) the Coroner recommended that there be centrally located circulars and guidelines which all staff be required to read. In this case the deceased was not regularly observed and observations were not recorded.

In the case of the man who died at East Perth Lockup, police failed to comply with a number of procedures in their assessment and observation of the deceased. The response of the Secretary of the Western Australian Police Union, that police don't have a responsibility to look after 'crooks,' is an indicator of the attitudinal change still required by recommendation 122.

Four other cases involved prisons. In the case of the 33 year old man who died at Long Bay Prison (27NSW), the Coroner found that Long Bay Prison had not implemented his earlier recommendations concerning exchange of information between prison and medical officers. There was a series of mis-communications between prison and medical offices that eventually contributed to the man's death. The 30 year old woman who died in Mulawa Prison was not given medical attention despite evidence that she lay in her cell all night, moaning audibly. In the death of a 19 year old man at Parklea Prison (67NSW) the Coroner questioned whether the Prison Health Service comprehended their duty of care, after medical staff failed to communicate 'at risk' information to prison officers. As discussion under recommendation 152f indicates, there was a failure in many cases to communicate information between prison and medical staff. In the death of a 21 year old man at Rockhampton Prison on 2 April 1990 (14QLD) the Coroner found that prison officers did not understand procedures for dealing with inmates at risk and that these procedures were in need of development.

Courts in New South Wales have recently awarded damages to relatives of Aboriginal people who have died in custody on the basis that custodial officers and hospital staff breached their duty of care.⁴ It will be unfortunate if this is the method by which police and prison services comprehend their duty of care and subsequent responsibilities.

Recommendation 123 - Personal Accountability for Breaches of Instructions
That Police and Corrective Services establish clear policies in relation to breaches of departmental instructions. Instructions relating to the care of persons in custody should be in mandatory terms and  be both enforceable and enforced. Procedures should be put in place to ensure that such instructions are brought to the attention of and are understood by all officers and that those officers are made aware that the instructions will be enforced. Such instructions should be available to the public.

The existence of disciplinary procedures for breaches of instructions was not apparent in any of the ten cases discussed under recommendation 122. All jurisidctions claimed implementation except Tasmania who claimed part implementation.

In one of these cases (62NSW) the employees who were found to be extremely negligent by the coroner received counselling. In another case (67NSW), the Minister of Corrective Services held an investigation into the circumstances of the death, after a recommendation from the Coroner. The Board of Inquiry established by the Minister found that certain medical staff had breached guidelines but that the trauma of the experience and interview with the Board was sufficient discipline.

Recommendation 124 - De-briefing Following Incidents
That Police and Corrective Services should establish procedures for the conduct of de-briefing sessions following incidents of importance such as deaths, medical emergencies or actual or attempted suicides so that the operation of procedures, the actions of those involved and the application of instructions to specific situations can be discussed and assessed with a view to reducing risks in the future.

All jurisdictions claimed implementation except Tasmania which claimed part implementation. Coroners commented upon the deficiencies of de-briefing procedures in two cases. The Coroner in the death of a 19 year old man at Parklea Prison (67NSW) found that the debriefing procedure was inadequate and sessions were poorly attended by staff. Debriefing procedures were also inadequate following the death of a woman in Mulawa Prison in 1994 (62NSW). The Coroner in the death of a 24 year old man at Rockhampton Prison (14QLD) found that no procedures were put in place after the deaths to accompany an 'at risk' classification despite the self-induced death of two inmates at the Prison. The occurrence of indistinguishable deaths at certain institutions such as Townsville Watch-house, Rockhampton Watch-house, Yatala Prison and the police car chase deaths in Western Australia, raise questions as to the effective use of de-briefing procedures, systems of communication and information exchange.

De-briefing procedures should also be structured appropriately. In the case of the man who died in a Brisbane Police Van (53QLD), Commissioner Wyvil recommended that officers should provide independent statements of events before the debriefing procedure to avoid recollection being affected by the views of other officers.

2. Custodial Health and Safety: Police

There were 35 deaths in police custody from June 1989 to May 1996. Seventeen of these cases involved police pursuit. These deaths only raise issues of arrest and Aboriginal-police relations which are discussed in chapter 6. The remaining 18 cases involved deaths in police vans (4) and watch-houses (14). ⁵

In the latter cases the person sometimes died in hospital. In two of the cases the inquest had not commenced at the time of writing this Report, and consequently, coronial findings and legal submissions were unavailable.⁶

Almost all the cases involved people under the influence of alcohol or people whom the police presumed were under such an influence. ⁷ It is not surprising that the deaths were therefore concentrated in Queensland and Victoria where drunkenness has not been decriminalised. However, only two of the deaths were the direct result of drugs or alcohol. Six of the deaths were self-inflicted, seven from natural causes, and three from injuries.

Many of the cases could have been prevented if non-discretionary procedures recommended by the Royal Commission were put in place. As Table 8.2 shows, recommendations concerning assessment (R125, 126), regular nursing presence (R127a), protocols for intoxicated people (R127f(i)) and regular and careful checks on detainees (R137) were frequently breached. The most frequently breached recommendation was recommendation 133 which required training for police to identify those in distress as well as training to recognise the dangers and misconceptions associated with alcohol.

The decrease in deaths in police vans and cells, as noted in chapter 2, is welcome. This can be seen in Table 8.2 where breaches are concentrated in the first period. The decline in deaths in police cells may be, to a degree, a result of implementation of recommendations. It is also likely to be a result of speedier transfer of detainees to remand centres. As chapter 2 revealed, deaths that may have occurred in police cells now occur in prison, particularly self-inflicted deaths which occur in the early stages of detention.

Governments claimed full implementation of almost all recommendations concerning health and safety in police custody (see Part C Appendix). Tasmania does not support 140, 144, 145, 146 and 149.

Table 8.2 Custodial Health and Safety: Police

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Recommendation 125 - Introduction of a Screening Form
That in all jurisdictions a screening form be introduced as a routine element in the reception of persons into police custody. The effectiveness of such forms and procedures adopted with respect to the completion of such should be evaluated in the light of the experience of the use of such forms in other jurisdictions.

Coronial summaries do not always reveal whether a screening assessment was carried out. Two of the early Queensland cases clearly indicate that no assessment occurred (3QLD, 5QLD).

In three other Queensland cases (21QLD; 25QLD; and 32 QLD) the completion of a comprehensive screening form would have revealed the need of the deceased for medical attention. Two of the deceased had serious head injuries and one had epilepsy. The death at East Perth Lockup (65WA) raised similar problems. The deceased stated to the police at reception that he was on medication for blood pressure, had chest pains, was a regular drinker, had been recently hospitalised and that he had a headache. However, his health was assessed by police as 'OK'.

The case of the death at Parklea Prison (67NSW) illustrated an effective police assessment form. Certain answers from interviewees lead to non-discretionary responsive action by police. In that case a prior suicide attempt automatically tagged the deceased as a high suicide risk. This approach compensates for the lack of police experience in detecting physical and mental health problems. Police forms should also have questions on symptoms, particularly for heart disease, as was recommended by Deputy Coroner Abernathy in the death at Broken Hill Prison (71NSW).

Recommendation 126 - Thorough Assessment of Screening Forms
That in every case of a person being taken into custody, and immediately before that person is placed in a cell, a screening form should be completed and a risk assessment made by a police officer or such other person, not being a police officer, who is trained and designated as the person responsible for the completion of such forms and assessment of prisoners. The assessment of a detainee and other procedures relating to the completion of the screening form should be completed with care and thoroughness.

In five cases the screening form was not completed thoroughly.⁸ In the death at Macquarie Fields Police Stations (39NSW) the form was filled out incorrectly and the police did not inquire of the deceased's Aboriginality. In the death at Bendigo Police Station, police did not believe the deceased when he said he was Aboriginal (31VIC). In the case at Gippsland Hospital (8VIC) only a perfunctory check was made by the police surgeon. In the two other cases police failed to pick up information as to the mental (1SA) and physical (2WA) health status of the deceased.

Recommendation 127 - Appropriate Health Care
That Police Services should move immediately in negotiation with Aboriginal Health Services and government health and medical agencies to examine the delivery of medical services to persons in police custody. Such examination should include, but not be limited to, the following:

1. The introduction of a regular medical or nursing presence in all principal watch-houses in capital cities and in such other major centres as have substantial numbers detained;
2. In other locations, the establishment of arrangements to have medical practitioners or trained nurses easily available to attend police watch-houses for the purpose of identifying those prisoners who are at risk through illness, injury or self-harm at the time of reception;
3. The involvement of Aboriginal Health Services in the provision of health and medical advice, assistance and care with respect to Aboriginal detainees and the funding arrangements necessary for them to facilitate their greater involvement;
4. The establishment of locally based protocols between police, medical and para-medical agencies to facilitate the provision of medical assistance to all persons in police custody where the need arises;
5. The establishment of proper systems of liaison between Aboriginal Health Services and police so as to ensure the transfer of information relevant to the health, medical needs and risk status of Aboriginal persons taken into police custody; and
6. The development of protocols for the care and management of Aboriginal prisoners at risk, with attention to be given to the specific action to be taken by officers with respect to the management of:

   i. intoxicated persons;
   ii. persons who are known to suffer from illnesses such as epilepsy, diabetes or heart disease or other serious medical conditions;
   iii. persons who make any attempt to harm themselves or who exhibit a tendency to violent, irrational or potentially self-injurious behaviour;
   iv. persons with an impaired state of consciousness;
   v. angry, aggressive or other wise disturbed persons;
   vi. persons suffering from mental illness;
   vii. other serious medical conditions;
   viii. persons in possession of, or requiring access to, medication; and
   ix. such other persons or such situations as agreed.

In seven cases it was evident that there was no regular medical nursing presence in the watch-houses in accordance with recommendation 127a. (39NSW, 5QLD 21QLD 25QLD 38QLD, 65WA). The presence of nursing and medical staff is critical to compensate for police inexperience in detecting medical conditions in accordance with recommendations 125, 126, 133. Likewise a number of cases clearly indicated the non-involvement of Aboriginal Health Services (8VIC, 1SA, 65WA). Furthermore, in none of the case was there an attempt to secure medical files or information from other sources.

There was also a lack of protocols under recommendation 127f. There were no protocols for dealing with intoxicated people under recommendation 127f in a large number of cases (3QLD, 5QLD, 21QLD, 25QLD, 38QLD, 53QLD, 8VIC, 31VIC, 38VIC). In A number of other cases it was clear that there was no protocols for:

• heart disease (65WA) - recommendation 127f(ii);
• self-harm (39NSW) - recommendation 127f(iii); and
• medication (65WA) - recommendation 127f(viii)

Recommendation 128 - Care for Corrective Services Prisoners in Police Lockups
That where persons are held in police watch-houses on behalf of a Corrective Services authority, that authority arrange, in consultation with Police Services, for medical services (and as far as possible other services) to be provided not less adequate than those that are provided in correctional institutions.

Two case concerned prisoners held in police watch-houses on behalf of Corrective Services: the woman who died at Macquarie Fields (39NSW) and the woman who died at Mulawa prison (62NSW). In the former case the Coroner in that case criticised the arrangement whereby sentenced prisoners were held in police cells in breach of the court warrant, the Prison Act and the Police Commissioner's instructions. He also expressed concern at the standard of care at the Police Station. In the latter case the deceased was in medical distress, and was on record as suffering a serious heart condition, but was not given medical attention on either of the two occasions that she was held in police custody on behalf of Corrective Services in the days prior to her death. A form indicated that the deceased was sick and had endocarditis.

Recommendation 129 - Breath Analysis Equipment to Confirm Drunkenness
That the use of breath analysis equipment to test the blood alcohol levels at time of reception of  persons be thoroughly evaluated by Police Services in consultation with Aboriginal Legal Services, Aboriginal Health Services, health departments and relevant agencies.

There were two cases in Queensland and Victoria in which people who died in custody after being charged with public drunkenness were found not to be intoxicated (38QLD, 8VIC). These cases indicate that this recommendation has merit, although no jurisdiction has implemented it.

Recommendation 130 - Transfer of Medical Information
That:

1. Protocols be established for the transfer between Police and Corrective Services of information about the physical or mental condition of an Aboriginal person which may create or increase the risks of death or injury to that person when in custody;
2. In developing such protocols, Police Services, Corrective Services and health authorities with Aboriginal Legal Services and Aboriginal Health Services should establish procedures for the transfer of such information and establish necessary safe-guards to protect the rights of privacy and  confidentiality of individual prisoners to the extent compatible with adequate care; and
3. Such protocols should be subject to relevant ministerial approval.

A number of New South Wales cases revealed that relevant health information was not successfully transferred between police and prisons. In the case of the man who died at Westmead Hospital (7NSW), the mother of the deceased had told a police officer of the deceased's ear problems but this information was not passed onto the prion. In the case of the 19 year old man who died at Parklea Prison (67NSW), the Board of Inquiry (Response of Minister to the Coroner) found that police assessment forms were generally not available or not used in the assessment of remand or freshly sentenced prisoners at Parklea Prison. The need for improvement in prison reception procedures is discussed in recommendation 157. For discussion of confidentiality issues see recommendation 152e and 153b.

Recommendation 131 - Police Officers to Record Observations of Prisoners
That where police officers in charge of prisoners acquire information relating to the medical condition of a prisoner, either because they observe that condition or because the information is voluntarily  disclosed to them, such information should be recorded where it may be accessed by any other police officer charged with the supervision of the prisoner. Such information should be added to the screening form referred to in Recommendation 126 or filed in association with it.

In the cases at Rockhampton Police Watch-house (25QLD) and East Perth Lockup (65WA) the deceased were vomiting during the night before they died. This was not noted by police. Both of the detainees died of natural causes.

Recommendation 132 - Passing of Information to Incoming Shift
That:

1. Police instructions should require that the officer in charge of an outgoing shift draw to the attention  of the officer in charge of the incoming shift any information relating to the well being of any prisoner  or detainee and, in particular, any medical attention required by any prisoner or detainee;
2. A written check list should be devised setting out those matters which should be addressed, both in writing and orally, at the time of any such handover of shift; and
3. Police Services should assess the need for an appropriate form or process of record keeping to be devised to ensure adequate and appropriate notation of such matters.

In the case at East Perth Lockup (65WA) there was no exchange of information between the Officers in Charge as to the health of the deceased. The Officer in Charge was completely unaware as to relevant information concerning the deceased. The issue did not arise in other cases as relevant information in the screening process was not obtained or there was no change of shifts. This recommendation is also important in relation to prisons, as illustrated by the death of the young man at Parklea Prison (67NSW).

Recommendation 133 - Basic Training to Identify Conditions
That:

1. All police officers should receive training at both recruit and in-service levels to enable them to identify persons in distress or at risk of death or injury through illness, injury or self-harm;
2. Such training should include information as to the general health status of the Aboriginal population,  the dangers and misconceptions associated with detaining unconscious or semi-rousable persons and  the specific action to be taken by officers in relation to those matters which are to be the subject of  protocols referred to in recommendation 127;
3. In designing and delivering such training programs, custodial authorities should seek the advice and assistance of Aboriginal Health Services and Aboriginal Legal services; and
4. Where a police officer or other person is designated or recognized by a police service as being a person whose work is dedicated wholly or substantially to cell guard duties then such person should receive a more intensive and specialised training than would be appropriate for other officers.

This recommendation was made in the Interim Report (R14) and was the most frequently breached recommendation. The cases clearly revealed that police were generally unable to identify detainees at risk. This indicates the need for more intensive police training beyond the cursory one or two day courses at police academies. Both 'on the job' training and recruit training in custody procedures needs to be improved in all jurisdictions. The training programs should be designed in conjunction with experts in the field of custodial procedures and Aboriginal Organisations with an interest in custodial issues. The recommendation also recognises the critical need for non-discretionary procedures such as screening assessments, checking of detainees and a nursing and medical presence.

In four of the cases the deceased were arrested for drunkenness when they were suffering from illnesses and injury (21QLD, 25QLD, 38QLD, 8VIC). Police assumed from previous charges for drunkenness, or the deceased's behaviour, that they were intoxicated. Two of the cases involved persons with epilepsy and two cases of head injuries. The need for police to distinguish between intoxication and illness is clearly set out in recommendation 133b and Interim Report recommendation 14.

The use of sobering-up facilities is relevant to this recommendation. Sobering up facilities are a welcome alternative from police cells. However, police need training to ensure that people suffering from other illnesses are not inappropriately conveyed to such facilities. A permanent nursing presence is also needed at sobering-up facilities. The death at a sobering up centre in South Australia (A1SA) is illustrative. The police assumed the deceased was drunk and drove him to a centre when the deceased was actually suffering from a fractured skull.

In four other cases the deceased were placed in the back of police vans for long periods of time (42NSW, 50NT, 53QLD, 36VIC). The case in the Northern Territory was not listed as a breach of this recommendation as the inquest has not yet commenced. In all cases the deceased were under the influence of drugs and in three of the cases exhibited symptoms of other illnesses. The placement of the detainees unobserved and handcuffed in police vans for significant periods of time is extremely dangerous. The officer in charge of the safety in custody taskforce in New South Wales is not of senior rank, indicating that this area is not a priority for the Service.

In cases involving self-inflicted hanging none of the deceased was recognised as a suicide risk (39NSW, 96NT, 3QLD, 1SA, 31VIC). In two of the cases there were signs of suicidal intent. In the case at the Ceduna Police Station (1SA) the deceased was angry and frustrated at arrangements concerning transport to court after being denied bail. In the case of the man who died at Bendigo Police Station (31VIC) the police disbelieved the deceased's statement that he was Aboriginal, did not allow for withdrawal from alcohol and consider the deceased's anxiety about returning home to his wife after losing a sum of money (31VIC). Recognition of the risk of self-harm is difficult. However, police should be aware of the propensity of detainees to commit suicide within the early stage of detention. They should therefore be acutely vigilant and on the look-out for signs of self-harm.

Other cases involved natural causes and injuries. In the death at Rockhampton Watch-house (5QLD) the deceased was unconscious and black ants were crawling over his clothes and hair (5QLD). Instead of being taken to a hospital he was arrested for public drunkenness. In the death at Palm Island Watch-house (32QLD) the deceased had serious head injuries but was arrested for public drunkenness and taken to police cells. In the East Perth Lockup case (65WA) the deceased responded positively to questions about chest pain and medication yet no action was taken. He later died of heart disease contributed to by alcohol withdrawal. In the case at Port Headland Lockup the deceased died of a heart attack after being arrested for drunkenness (2WA). From the short coronial summary it is unclear whether he exhibited signs of heart disease or whether he was in fact intoxicated.

Recommendation 134 - Humane Treatment of Detainees

That police instructions should require that, at all times, police should interact with detainees in a  manner which is both humane and courteous. Police authorities should regard it as a serious breach of discipline for an officer to speak to a detainee in a deliberately hurtful or provocative manner.

The cases in Brisbane Police custody (53QLD) and Gippsland Sale Hospital (8VIC) raise questions as to humane treatment. In the first case the deceased was handcuffed and placed face down in a police vehicle. The police van was then driven around the area looking for more of the group while the deceased suffered a heart attack. In the second case the deceased was semi-rousable yet handcuffed and held in police cells for 10 hours.

Recommendation 135 - Transport semi-rousable persons to hospital
In no case should a person be transported by police to a watch-house when that person is either unconscious or not easily roused. Such persons must be immediately taken to a hospital or medical practitioner or, if, neither is available, to a nurse or other person qualified to assess their health.

This recommendation was earlier made in the Interim Report and recommended by a Coroner in the second post-Royal Commission death in Queensland (5QLD). However, this recommendation was breached in six cases. In two of the cases the deceased was unconscious (5QLD, 21QLD) while in four cases the deceased was semi-rousable due to injuries and illness (32QLD, 38QLD, 53QLD and 36VIC). In all cases it was assumed that the deceased were simply intoxicated.

Recommendation 136 - Transport semi-rousable persons in cell to hospital
That a person found to be unconscious or not easily rousable whilst in a watch-house or cell must be immediately conveyed to a hospital, medical practitioner or nurse. (Where quicker medical aid can be summoned to the watch-house or cell or there are reasons for believing that movement may be dangerous for the health of the detainee, such medical attendance should be sought).

Four of the persons mentioned in recommendation 135 were taken back to watch-houses and cells (5QLD, 21QLD, 32QLD and 38QLD) and not subsequently taken to a hospital. In another case the deceased, who was semi-rousable, was actually taken from a hospital by police (8VIC).

Recommendation 137 - Observation
That:

1. Police instructions and training should require that regular, careful and thorough checks of all detainees in police custody be made;
2. During the first two hours of detention, a detainee should be checked at intervals of not greater than fifteen minutes and that thereafter checks should be conducted at intervals of no greater than one hour;
3. Notwithstanding the provision of electronic surveillance equipment, the monitoring of such persons in the periods described above should at all times be made in person. Where a detainee is awake, the check should involve conversation with that person. Where the person is sleeping the officer should ensure that the person is breathing comfortably and is in a safe posture and otherwise appears not to  be at risk. Where there is any reason for the inspecting officer to be concerned about the physical or mental condition of a detainee, that person should be woken and checked; and
4. Where any detainee has been identified as, or is suspected to be, a prisoner at risk then the prisoner or detainee should be subject to checking which is closer and more frequent than the standard.

This recommendation was the most frequently breached recommendation after 133. Coroners have stated that the regularity and type of checks on detainees must depend on the circumstances (see profile 4NSW for example).

Four of the cases involved deaths in police vans (42NSW, 50NT, 53QLD and 38VIC). ⁹ As arrestees are obscured from view in police vans, constant checks need to be maintained. This is particularly so if the arrest involved force and the deceased is handcuffed, as happened in three of the cases. Police will often have little knowledge of the person's health and vigilance is therefore necessary. In the death of an 18 year old man in Brisbane on 13 November 1993 (53QLD), Commissioner Wyvil recommended that consideration be given to the establishment of a means of communication between the occupants of special purpose vehicles of the type involved in this case and those persons imprisoned in the secure area of those vehicles.

In four other cases coroners criticised the frequency of checks (39NSW, 3QLD, 21QLD and 1SA). In the first Queensland case surveillance equipment had not been installed in the Police Watch-house as previously recommended by the Coroner, while in 21QD the police left police aides in charge, and made infrequent checks on detainees from the car park or as they drove past.

In three other cases it was clear that checks were not sufficient. In the death at Sale Police Station (8VIC) the deceased was not checked every 15 minutes for the first two hours, as required. The man had been wrongly arrested for drunkenness in a public hospital while semi-conscious after suffering an epileptic fit. In the death of a 34 year old man at Rockhampton Watch-house, the Coroner found that the deceased had been checked regularly during the night by police looking through the cell door. However, the findings are not convincing. Rigor mortis had set in by the morning.

That he had not arisen out of bed in almost 24 hours casts doubt on statements that appropriate checks took place. If checks took place they were clearly not diligent and adequate for a person in the condition of the deceased. There was no reference in the findings to written records of the checks. In the case of the death of a man in the Port Headland Lockup (2WA) in 1989 the Coroner found that hourly checks were made. The deceased had had been found staggering on a road and was arrested. The Royal Commission's interim report released eight months earlier had emphasised the need for more regular checks of intoxicated persons.

Recommendation 138 - Recording of Information
That police instructions should require the adequate recording, in relevant journals, of observations and information regarding complaints, requests or behaviour relating to mental or physical health, medical attention offered and/or provided to detainees and any other matters relating to the well being of detainees. Instructions should also require the recording of all cell checks conducted.

In seven cases observations were not recorded (39NSW, 21QLD, 25QLD, 38QLD, 8VIC, 31VIC and 65WA). As noted under recommendation 131, changes in medical condition were not noted in two cases (21QLD, 65WA).

Recommendation 139 -TV Monitoring
The Commission noted recent moves by Police services to install TV monitoring devices in police cells. The Commission recommends that:

1. The emphasis in any consideration of proper systems for surveillance of those in custody should be on human interaction rather than on high technology. The psychological impact on the use of such equipment on a detainee must be borne in mind, as should its impact on that person's privacy. It is preferable that police cells be designed to maximise direct visual surveillance. Where such equipment has been installed it should be used only as a monitoring aid and not as a substitute for human interaction between the detainee and his/her custodians; and
2. Police instructions specifically direct that, even where electronic monitoring camera are installed in police cells, personal checks be maintained.

The issue of electronic monitoring was raised in two cases. In profile 3QLD the coroner recommended video surveillance equipment, but did not address the issue of cameras being used with proper human interaction and checks of detainees. In profile 31VIC, where the deceased was found hanging in a shower recess hidden to surveillance cameras, the detainee had been physically checked 35 minutes earlier. The coroners generally did not comment on the level of human interaction in cases where electronic monitoring was used.

Recommendation 140 - Alarm System
That as soon as practicable, all cells should be equipped with an alarm or intercom system which gives direct communication to custodians. This should be pursued as a matter of urgency at those police watch-houses where surveillance resources are limited.

In the death at Macquarie Fields Police Station (39NSW) where the Coroner recommended installation of computer operated alarm buttons in police cells. In two prison deaths there was no alarm system in the cells (6NSW and 85WA).

Recommendation 141 - Supervision
That no person should be detained in a police cell unless a police officer is in attendance at the watch-house and is able to perform duties of care and supervision of the detainee. Where a person is detained in a police cell and a police officer is not so available then the watch-house should be attended by a person capable of providing care and supervision of persons detained.

In the Mornington Island Watch-house case (21QLD), Aboriginal community police aides were left to supervise the deceased in breach of instructions and police only checked as they drove past the watch-house. The recent death on Tiwi Island indicates the problem of this recommendation for remote areas and communities (96NT). Procedures should be put in place so that other people, eg community wardens, can supervise detainees if police officers are elsewhere.

Recommendation 142 - Padded Cells
That the installation and/or use of padded cells in police watch-houses for punitive purposes or for the management of those at risk should be discontinued immediately.

There was no information presented by the case profiles.

Recommendation 143 - Proper Meal at Regular Times
All persons taken into custody, including those persons detained for intoxication, should be provided with a proper meal at regular meal times. The practice operating in some jurisdictions of excluding persons detained for intoxication from being provided with meals should be reviewed as a matter of priority.

Most of the cases revealed that meals were provided to the deceased. However, in the death of a woman at Mulawa (62NSW) sandwiches were found in the deceased's cell, and, although it was apparent that she was very ill, no-one had attempted to ensure that she could eat them or receive more appropriate nourishment.

Recommendation 144 - Shared cells
That in all cases, unless there are substantial grounds for believing that the well being of the detainee or other persons would be prejudiced, an Aboriginal detainee should not be placed alone in a police cell. Wherever possible, an Aboriginal detainee should be accommodated with another Aboriginal person. The views of the Aboriginal detainees and such other detainee should be sought. Where placement in a cell alone is the only alternative the detainee should thereafter be treated as a person who requires careful surveillance.

Quality of surveillance or monitoring is dependent on individual psychological assessment following the physical isolation of a detainee. A number of profiles in this report outline instances where inadequate supervision and monitoring of detainees apparently alone in police cells has contributed to deaths. See, for example 39NSW, 25QLD, 32QLD, 38 QLD, 8VIC, 31VIC. These examples count for few of the deaths in custody in the period of reporting, although they are a significant ratio of the group who died in police custody. It is noted that increasingly the general practice of most police lockups is to 'encourage Aboriginal prisoners to share cells with each other'.' ¹⁰ Tasmania does not support this recommendation.

Recommendation 145 - Aboriginal Visitor Scheme
That:

1. In consultations with Aboriginal communities and their organizations, cell visitor schemes (or schemes serving similar purposes) should be introduced to service police watch-houses wherever practicable;
2. Where such cell visitor schemes do not presently exist and where there is a need or an expressed interest by Aboriginal persons in the creation of such a scheme, government should undertake negotiations with local Aboriginal groups and organization towards the establishment of such a scheme. The involvement of the Aboriginal community should be sought in the management and operation of the schemes. Adequate training should be provided to persons participating in such schemes. Governments should ensure that cell visitor schemes receive appropriate funding.
3. Where police cell visitor schemes are established it should be made clear to police officers performing duties as custodians of those detained in police cells that the operation of the cell visitor schemes does not lessen, to any degree, the duty of care owed by them to detainees; and
4. Aboriginal participants in cell visitor schemes should be those nominated or approved by appropriate Aboriginal communities and/organizations as well as by any other person whose approval is required by local practice.

The cases indicate that proper heed is not being paid to input into prisoner welfare potentially provided by the Aboriginal Visitor schemes.

The man who died in Bendigo police station in Victoria told police that he was Aboriginal, but they did not believe him (31QLD). As a result the Community Justice Panel was not informed when the deceased was taken into custody.

In the case of the woman who died following her arrest for drunkenness in Brisbane (38QLD) the police did not follow agreed protocols which set out the details to be given to Murri Watch, an Aboriginal organisation which diverts intoxicated persons from police custody. Murri Watch was contacted, and apparently told the deceased had soiled herself. The woman was incorrectly described as being intoxicated - in fact she had suffered a heart attack. The representative responded that he would let her sleep it off and pick her up in a few hours.

Watch-house procedures for recording notification of Murri Watch, and recording their response, were not complied with. The investigator specified that details should have included her inability to answer questions about her health; the lack of a detectable odour of alcohol; her impaired consciousness; her inability to stand, requiring her to be carried; the fact that she was not violent or aggressive; the arrangements made to clean up faeces; and the lack of any medical examination.

In the case of the man who died in Townsville Prison in 1994 (64QLD), the Police and Corrective Services Minister denied that prison authorities had been informed by the Gurrindal Cell Visitors Program that the deceased had made suicide threats while at the Townsville Watch-house prior to being taken to the Remand Centre. ¹¹ An Indigenous woman appointed to the investigation team made a formal complaint about the refusal to grant her access to information which tended to corroborate that claim, including a form indicating that the deceased was 'at risk' of self-harm.

The case of the man who died at the East Perth Lockup in 1994 (65QLD) visitors from the Aboriginal Visitor Scheme noted in the Visitors Book at the Police Station that the deceased's medication was at the night shelter. Police did not become aware of this information until after the death, as there was no procedure for examining the Visitors Book.

Recommendation 146 - Visits from Family and Friends
That police should take all reasonable steps to both encourage and facilitate the visits by family and friends of persons detained in police custody.

In the case of the man who died in Arthur Gorrie Remand Centre in 1993 (45QLD) the Coroner strongly criticised the denial of a request for a visit by the immediate family. The death raises the issue of police recommendations extending to remand facilities.

The deceased had been moved from the Brisbane Watch-house on the day of his arrest, on the basis that he was a suicide risk. The Remand Centre rules allowed only week-end visits. Prisoners are extremely vulnerable to self harm and suicide in the initial stages of their incarceration, with the proportion of deaths among remand prisoners being three and a half times greater than in the general prison population.¹²

Recommendation 147 - 'At Risk' Notification to Families
That police instructions should be amended to make it mandatory for police to immediately notify the relatives of a detainee who is regarded as being 'at risk', or who has been transferred to hospital.

Unfortunately, there was little information on this recommendation. However, in the case of the man who died in Arthur Gorrie Remand Centre in Queensland (45QLD) the Coroner was critical of the denial of a request by the immediate family to visit the deceased, who had been moved from the Brisbane Watch-house on the day of his arrest on the basis that he was a suicide risk. There was no indication that the family was informed of this. Their request to visit was flatly refused. This is a crucial recommendation, and coroners must begin to address it.

Recommendation 148 - Safe cells
That whilst there can be little doubt that some police cell accommodation is entirely substandard and must be improved over time, expenditure on positive initiatives to reduce the number of Aboriginal people in custody discussed elsewhere in this report constitutes a more pressing priority as far as resources are concerned. Where cells of a higher standard are available at no great distance, these may be able to be used. More immediate attention must be given to programs diverting people form custody, to the provision of alternative accommodation to police cells for intoxicated persons, to bail procedures and to proceeding by way of summons or caution rather than by way of arrest. All these initiatives will reduce the numbers for whom cell accommodation is required. Where, however, it is determined that new cell accommodation must be provided in areas of high Aboriginal population, the views of the local community and organizations should be taken into account in the design of such accommodation. The design or re-design of any police cell should emphasize and facilitate personal interaction between custodial officers and detainees and between detainees and visitors.

In the case of the death of the 19 year old in the Ceduna police cells (1SA), the ALRM noted that conditions in the cells were poor: it was the middle of winter, the cells were spartan, cold and lacking in adequate exercise space. New cells were in construction by the time the Coroner made his findings.

The Royal Commission noted the poor conditions in the East Perth Lockup in the course of an inquiry into a death there in 1986. ¹³ The ALS of Western Australia indicated that conditions at the cells had not improved by the time another Aboriginal man died in the cells in late 1994 (65WA).

The Rockhampton Watch-house, the site of a death in 1991 (25QLD), was a dilapidated facility. The Coroner did not address this issue. It is now being upgraded, but there has been controversy over the building of underground cells. The Human Rights Commissioner has indicated that access to courtyards is essential if the facility is to comply with the relevant international covenants. ¹⁴ The staffing of the watch-house by inexperienced officers was severely criticised by the Coroner investigating the death.

Recommendation 149 - Flexible Police Custody Arrangements
That Police Services should recognise, by appropriate instructions, the need to permit flexible custody arrangements which enable police to grant greater physical freedoms and practical liberties to  Aboriginal detainees. The Commission recommends that the instructions acknowledge the fact that in appropriate circumstances it is consistent with the interest of the public and also the well being of detainees to  permit some freedom of movement within or outside the confines of watch-houses.

Submissions from the ALRM at the inquest into the death of a 19 year old at the Ceduna Police Station, indicated that flexible custody arrangements recommended by the Royal Commission had been discontinued (1SA). Case profiles also indicated that inappropriate restrictions are being placed on access to exercise yards (1SA, 2WA).

In the case of the death of a woman at Macquarie Fields Police Station (39NSW) there was no exercise yard, although the Coroner noted that two yards were planned for the station.

3. Custodial Health and Safety: Prison

Sixty Aboriginal deaths occurred in prison custody. Of these deaths, 43 have been investigated by coroners. In two other deaths there is sufficient information avaialable to be examined for implementation of recommendations. As noted earlier, the detail of Royal Commission recommendations regarding police custody is useful in interpreting recommendations concerning health and safety in prisons.

The case studies indicate a wide variance in the standard of care as well as idiosyncratic problems at state, territory and individual prison level.

Table 8.3 lists the frequency of breaches. The most frequently breached recommendation was 152f which concerns exchange of information between medical and prison staff. Other frequently breached recommendations include protocols for prisoners at risk of self-harm (R152g(iv)), cross-cultural training for medical staff (152a) and prison staff (155) and the securing of medical information about prisoners (R157). Victoria and Northern Territory claim implementation of the majority of the eight recommendations while the other jurisidctions only claim part implementation (see Part C Appendix). The implementation of the Northern Territory is difficult to evaluate as the inquests into the three deaths that occurred in Northern Territory prisons have not been completed or commenced.

Table 8.3 Breaches of Recommendations: Prison Custodial Health and Safety

Click here to see the table

Recommendation 150 - Equivalent Standard of Medical Care in Custody
That the health care available to persons in correctional institutions should be of an equivalent standard  to that available to the general public. Services provided to the inmates of correctional institutions should include medical, dental, mental health, drug and alcohol services provided either within the correctional institution or made available by ready access to community facilities and services. Health services provided within correctional institutions should be adequately resourced and be staffed by appropriately qualified and competent personnel. Such services should be both accessible and appropriate to Aboriginal prisoners. Correctional institutions should provide 24 hour access to medical practitioners and nursing staff who are either available on the premises, or on call.

A breach of recommendation 150 was only recorded when the first part of recommendation 150 was not implemented, where there was a not an equivalent standard of health care in the prison compared to the community. The remainder of the elements of recommendation 150 are reflected in recommendations 151-157.

In seven of the 43 cases there was sufficient information to conclude that prison health services were clearly below community standards. While there was little information available from Queensland coronial inquests, the lack of protocols for self-harm raise serious doubts as to quality of health care in that state's prison system.

Two cases in New South Wales indicated significant problems with Maitland and Mulawa Prison. In the case of a juvenile who died at Maitland Prison (6NSW) the deceased received no assessment on arrival at Maitland Prison, was put in a cell without a light switch or buzzer. The deceased was a juvenile, mentally unstable and it was his first time in an adult prison. He committed suicide three days later.

The level of medical services at Mulawa was put under scrutiny in the case of the woman who died at Mulawa Prison in 1994 (62NSW). Nursing staff did not act on information, provided by prison staff, regarding the deceased's health, for four days. The deceased was subsequently misdiagnosed by the prison doctor after she failed to consult her records. The nurse actually stated during the inquest, in response to the question 'this wouldn't happen in a proper hospital': 'It's extraordinary circumstances within a gaol, it's not like a hospital at all.' Nursing staff also failed to take appropriate action after being informed that the deceased was suffering from more than drug withdrawal. Although medical files on record with Corrective Services indicated a serious heart condition there was no indication that a stethoscope was ever used on the deceased. The Coroner noted that the State Director for Nursing Services for Corrections Health Services gave evidence that a large number of changes were being made at Mulawa Prison. In 1994, a House of Representatives Committee found that there were frequent attempts at suicide at Mulawa Prison while very few attempts occurred at Norma Parker Prison, the other women's prison in New South Wales. ¹⁵

Many of the deaths in Queensland indicated an inadequate standard of care. The rate of prison suicide was almost double the national average (see recommendation 152g). In eight of the nine investigated deaths there were no protocols for prisoners at risk of self-harm. In other cases in Queensland it was clear that the level of psychiatric care was also lacking (see recommendation 151). In two Queensland cases there was sufficient evidence (generally not available from Queensland coronial summaries) that the standard of care was below community standards (34QLD, 43QLD).

In the case of the man who died at Mobilong Prison (20SA), the Coroner found that due to 'an avoidable lack of information, confused communications, misinterpretation of instructions and lack of reasonable expedition' there was an unexcusable delay of three hours in the deceased receiving medical care for heart disease. He was certified dead on arrival at the hospital. While the case of the man who died at Yatala Labour Prison (60SA) indicates improvement in medical care, the six deaths in South Australia prisons in 1995 (half of the deaths since the Royal Commission) raise questions as to the adequacy of medical care. ¹⁶ Only one coronial inquest into these deaths has been completed. In the case of the 29 year old man who died at Adelaide Remand Centre the Coroner found serious problems with the record-keeping of the Prison Medical Service and the lack of protocols for urgent situations. In this case the deceased had heart disease.

There has only been one death in a prison in Tasmania, the man who died at Risdon Prison (30TAS). The Coroner found that the level of psychiatric services was inadequate. The Aboriginal Legal Service had also submitted that there was a lack of multi-prisoner cells in the prison hospitals but this was not addressed by the Coroner.

In Western Australia, four of the five deaths in prison have been investigated. However, in the three latter cases there was little consideration of prison health services: 33WA (Greenough Regional Prison); 56WA (Canning Vale Prison); and 57WA(Greenough Regional Prison). In the first case, the 35 year old man who died at Canning Vale Prison (23WA), the Coroner found that the 'medical attention given to the deceased was generally appropriate' although he noted that the deceased had no confidence in the Prison Medical Service. He further held that the fact of incarceration was not a significant factor in the death and 'he was at equal risk of a fatal heart attack if he was confined in prison or was living in the community'. The Coroner, however, did not address submissions of the ALS concerning information flows and screening procedures and the keeping of medical records. The deceased at the time was also trying to secure the visit of a independent medical practitioner. The Coroner responded to this issue by stating that 'the absence of freedom of choice is ...the real sanction for behaviour which is not acceptable to society'. This statement is contrary to recommendation 150 which calls for equivalent standard of care and access to community facilities. As coroners in New South Wales have repeatedly stated, the punishment is the deprivation of liberty. It is not the denial of adequate health care and medical services.

There have been three deaths in prisons in the Northern Territory. However, none of them has been the subject of a completed inquest.

While some Prison Medical Services have made efforts to improve their performance, and have made progress, they are still constrained by grossly inqdequate funding.

Recommendation 151
The Commission recognises that there are limited numbers of psychiatrists with such experience. The Commission notes that, in many instances, medical practitioners who are or have been employed by Aboriginal Health Services are not specialists in psychiatry, but have experience and knowledge which would benefit inmates requiring psychiatric assessment or care.

Nine cases demonstrated that psychiatric services in a number of prisons were inadequate. The cultural appropriateness of psychiatric services in most prisons remains a continuing problem. The discussion under recommendation 152g(vi) also raises the issues of appropriate funding for mental health services within prisons.

A death in 1989 in New South Wales (6NSW) revealed an almost total lack of psychiatric facilities at Endeavour House (a juvenile institution) and Maitland Prison where the deceased died. In the recent case of the man who died at Parklea Prison (67NSW) in December 1994, the deceased was referred to the prison psychiatrist after being assessed on reception as a suicide risk. The deceased died four days later without having seen the psychiatrist. The lack of mental health facilities at Mulawa Prison is apparent in the case of the woman who died at Mulawa Prison (62NSW). It is noted in the Justice Under Scrutiny Report. ¹⁷

In Queensland the situation with regard to mental health is more alarming. In the case of the 17 year old juvenile who died at Sir David Longlands Prison (34QLD), psychiatric services were limited to a visiting semi-retired psychiatrist who kept no records of his visits with the deceased. The deceased was not seen by the psychiatrist after he first cut his wrist, as the psychiatrist was on leave and there was no replacement. The recent death at Sir David Longlands Prison (88QLD), although not investigated, indicates there may have been improvement in psychiatric services at this prison. The first two deaths at Townsville Prison (43QLD and 64QLD) indicate that there was no access to psychiatric services, the prison having being described as not fit for human habitation. In a recent case at Borallan Prison (74QLD) the quality of the psychiatric assessment is placed in question. The psychiatrist did not have the deceased's file and did not know of the deceased's Aboriginality. As noted above, Queensland has the highest rate of suicide in prison.

In South Australia, the ALRM has raised questions as to the availability of culturally appropriate psychiatric and medical care for patients after the death of a man at Port Augusta Prison (73SA) on 27 March 1995.

In Western Australia, the availability of psychiatric services is raised as an issue in the death at Greenough Regional Prison (33WA). The other cases did not provide sufficient information as to the level of services.

In Tasmania, in the case of the man who died at Risdon Prison (30TAS) the Coroner found that the services of psychiatrist, in addition to the psychologist, were required, and that psychiatric services needed to be urgently upgraded.

Full implementation of this recommendation requires psychiatrists who possess knowledge and experience of Aboriginal patients. In the case of the man who died at Long Bay Prison (72NSW) on 1 March 1995, the Coroner found recommendation 151 had been implemented, as the psychiatrist had twelve months experience in a Northern Territory community. This may or may not reflect sensitivity to Aboriginal culture. Given the marked over-representation of Aboriginal prisoners in the system specialised care is not an unreasonable expectation.

In the inquest into the death at Port Augusta Prison the director of a psychiatric facility for prison inmates stated:

[T]here is lack of psychiatric expertise within the gaol system itself; there are very few psychologists employed; there is not many available social workers for mental health cases; there is a shortage of meaningful programmes in gaols for anybody with a mental health illness; there are no liaison services, nursing liaison services, between psychiatry and mental health and prison.

Recommendation 152
That Corrective Services in conjunction with Aboriginal Health Services and such other bodies as may be appropriate should review the provision of health services to Aboriginal prisoners in correctional institutions and have regard to, and report upon, the following matters together with other matters thought appropriate:

The high number of both deaths in prisons and recommendations breached (150-157) raises questions as to whether there has been a sufficient review of the provision of health services. As is clear from discussion under recommendation 152c, none of the cases indicated any involvement of Aboriginal Medical Services. Coroners have called for comprehensive reviews of prison medical services in a number of cases (27NSW, 67NSW, 34QLD, and 78SA).

The various sub-paragraphs of recommendation 152 are considered separately below as to whether the various matters have been implemented.

Recommendation 152a
The standard of general and mental health care available to Aboriginal prisoners in each correctional institution;

The cases in which recommendation 152a was recorded as a breach include the cases in which there was a breach of recommendation 150. These were cases in which it could be clearly said that the standard of health care was clearly below community levels (6NSW, 62NSW, 34QLD, 43QLD, 20SA, 73SA and 30TAS).

As there is not a recommendation explicitly concerned with record-keeping in prisons, unlike recommendations 131 and 138 which concern record-keeping in police watch-houses, it will be discussed here. Coroners frequently criticised prison medical services for failing to keep proper records (4NSW, 27NSW, 44NSW, 62NSW, 67NSW, 14QLD, 34QLD, 43QLD, 60SA, and 78SA). It was criticised by the Western Australia ALS in another case (23WA). In the case of the man who died at Adelaide Remand Centre (78SA), the Coroner made the following recommendations:

That the Prison Medical Service develop a series of clear protocols to assist both medical and nursing staff to take appropriate action in urgent situations; and

That the Prison Medical Service review its systems in relation to record-keeping so that case notes are kept up-to-date and reviewed for that purpose at appropriate intervals.

Recommendation 152b - Culturally Appropriate Services
The extent to which services provided are culturally appropriate for and used by Aboriginal inmates. Particular attention should be given to drug and alcohol treatment, rehabilitative and preventative education and counselling programs for Aboriginal prisoners. Such programs should be provided where possible, by Aboriginal people.

A number of cases contained information indicating that the deceased was consuming drugs and alcohol in prison (10NSW; 46NSW; 56WA) or was withdrawing from drugs and alcohol (62NSW; 67NSW; 58QLD; 60SA; 33WA; 57WA ). As the majority of Australian prisoners commit offences under the influence of drugs and/or alcohol this number is likely to be much higher if more information were available.

In most cases it was difficult to determine the availability of culturally appropriate services, particularly those concerning drugs and alcohol. Drug and alcohol workers are now used by the prison services in New South Wales (see 67NSW) and there is a methadone program (10NSW).

In the case of the 22 year old man who died at Yatala Labour Prison (60SA) the Coroner found that a lack of programs was due to staff cutbacks. The provision of such services is necessary to prevent the high rates of recidivism for both Aboriginal and non-Aboriginal prisoners. Programs for Aboriginal prisoners need to be culturally appropriate to take into account the cultural circumstances of drug and alcohol use. These services not only assist individual prisoners, they are ultimately a service to the community at large.

Recommendation 152c Aboriginal Health Services
The involvement of Aboriginal Health Services in the provision of general and mental health care to Aboriginal prisoners.

Involvement of Aboriginal Health Services was apparent in none of the cases. In the case of the 20 year old man who died at Long Bay Prison (72NSW), the Coroner found that an Aboriginal health worker may have been able to diffuse a situation where the deceased had become very aggressive. However, he found that the staff did not know of the deceased's Aboriginality (despite recommendation 156) and there was no Aboriginal Welfare Officer (despite recommendation 174) to ensure liaison. Similarly, the Coroner, in the case of the 20 year old man who died at Arthur Gorrie Remand Centre (45QLD), found a lack of involvement of Aboriginal health workers.

Recommendation 152d - Facilities for Behaviourally Disturbed
The development of appropriate facilities for the behaviourally disturbed;

In a number of cases it was apparent that there were insufficient facilities for those with mental health problems. The Coroner in the Parklea Prison case (27NSW) recommended:

That in respect of persons at risk or with serious behavioural problems or who are mentally disturbed, short of certified current psychiatric experience, a Crisis Intervention Unit be established for their accommodation and care until they are certified fit to return the routine of prison.

In the case of the 20 year old man who died at Long Bay Prison (72NSW) there were insufficient safe cells and the deceased was moved back to a normal cell where he later committed suicide.

The appropriateness of prison safe cell facilities is to be questioned. ¹⁸ While the NSW Corrective Services Department has commented that there has never been a suicide in a safe cell, profile 72NSW is an example of a suicide immediately after release from a safe cell.

The Royal Commission cautioned against the over-use of observation or isolation cells as a response to persons identified as at risk. ¹⁹ They noted research which indicated that suicide is more common in segregation or isolation cells. It was commented that ward or dormitory accommodation may be more appropriate in many crisis situations. The Royal Commission stated that in cases of isolation a high degree of personal interaction must occur. The need for external stimuli is also obvious. The provision of a chalk board in the cells, often used for traditional painting, in Murgon Police Station in Queensland is a good example of such an approach.

The only program which falls squarely within this recommendation in New South Wales is the Special Care Unit at Long Bay Gaol, where inmates can voluntarily undertake programs in anger management and other matters. It is a pity that such a beneficial facility has such a small capacity, and that the prisoners who use the facilities are often released into environments which limit the benefits of the programme.

Concerns about safe cells are illustrated in three cases. In the case of the man who died at Risdon Prison (30TAS) the coronial report notes that deceased, after threatening to kill himself, was put in Category A Special Risk Classification. The following day he was downgraded to Category B where he was allowed a cigarette and a book. It is questionable whether the obvious restrictiveness of category A is necessary or useful. ²⁰

In the case of the 27 year old man who died at Townsville Prison (43QLD), the deceased committed suicide in the observation cell after being sent there for 'strict observation'. However, he was treated like other prisoners and only checked every half an hour.

The helpfulness of current safe cells was raised in the death at Yatala Prison (73SA) where the Coroner found prisoners were reluctant to inform custodial and medical officers of the 'at risk' behaviour of other prisoners because it may result in prisoners being placed in observation cells

Recommendation 152e - Information Exchange: External Health Agencies
The exchange of relevant information between prison medical staff and external health and medical agencies, including Aboriginal Health Services, as to risk factors in the detention of any Aboriginal inmate, and as to the protection of the rights of privacy and confidentiality of such inmates so far as is consistent with their proper care.

Recommendation 152e is related to Recommendation 157, as the latter concerns the securing of medical information by prison medical services from hospitals on reception and transfer. The cases in which this recommendations are breached are discussed under recommendation 157. They include three cases where there was no exchange of information on a visit to a hospital from a prison (59QLD, 78SA, 57WA) and three cases where the deceased had a significant medical history but this was not obtained from hospital or health services (37NSW; 74QLD; and 73SA). The need for 'risk flagging' system, as suggested by the Royal Commission and evident in recommendation 152e, is discussed under recommendation 157.

Recommendation 152e also concerns transfer of information from prison medical services to hospitals. In the case of the man who died at Mobilong Prison (20SA), there were a series of procedural breakdowns. The Coroner recommended that procedures be in place so that medical records accompany a prisoner on visits to a hospital.

Recommendation 152f - Information Exchange: Medical and Prison Staff
The establishment of detailed guidelines governing the exchange of information between prison medical staff, corrections officers and correction administrators with respect to the health and safety of prisoners. Such guidelines must recognise both the rights of prisoners to confidentiality and privacy and the responsibilities of corrections officers for the informed care of prisoners. Such guidelines must also be public and be available to prisoners;

This recommendation was breached in 14 cases and is a recurring theme through the case profiles. The recommendation was breached in all jurisdictions except Northern Territory. In the Northern Territory inquests into three prison deaths have not been completed.

In ten cases, prison officers were not informed by Prison Medical Services as to the suicidal risk of the prisoner or remandee (10NSW, 27NSW, 63NSW, 67NSW, 47VIC, 30TAS, 13QLD, 14QLD, 34QLD, 59QLD). In some cases, prison officers were completely unaware of the deceased's suicide risk while in other cases Medical Services did not instruct prison officers as to appropriate action. If action had been taken, such as shared cell or safe cell, regular checks and removal of materials used for self-harm, these deaths may well have been prevented.

These communication breakdowns were graphically illustrated in the case of the 35 year old man who died at Parklea Prison (27NSW). Prison authorities did not follow the advice of the psychiatrist regarding the appropriate prison to which the deceased should be transferred. Prison officers subsequently failed to place the deceased in a shared cell due to his suicide risk. This was because the nurse did not communicate the reasons for such action because of concern for confidentiality.

In two cases, prison officers were unaware of the deceased's illness. In the death at Lithgow Prison (26NSW) prison officers were unaware of the deceased's epilepsy which required he share a cell in the event a fit occurred. In the case at Mobilong Prison (20SA) there were a series of mis-communications which resulted in long delays in taking the deceased to hospital for treatment of heart disease.

In the death at Port Augusta Prison (73SA), the Prison Medical Service did not inform custodial officers that the consequences of the deceased not taking his anti-depressant medication. They also did not pass on their concerns to doctors treating the deceased.

Communication failures from prison officers to nursing staff occurred in one case. In the case at Mulawa Prison (62NSW) prison officers had communicated to nursing staff that the deceased had endocarditis (heart disease). Nursing staff, however, did not properly record the information and there was a significant delay in their taking appropriate action.

A related issue is the communication by prisoners to custodial and medical staff of medical concerns about other prisoners. The Coroner in the death at Yatala Labour Prison on 17 March 1995 (60SA) noted that inmates did not trust the few social workers. In the death at Canning Vale Prison (56WA) the Coroner noted the adversarial nature of prison where prisoners would not inform on each other. In that case, two inmates knew the deceased was not rousable, after injecting himself with heroin. They did not inform prison officers as to his condition, even after the condition of one of the inmates, who had also taken the drug, was noticed by prison officers and an injection given to counteract the its effects.

The Coroner in a later death at Yatala Prison prison (73SA) noted that there was a 'code of silence' among prisoners which prevented them from informing officers as to at risk' behaviour of other inmates, particularly when this may have unpleasant consequences for the prisoners, including being placed in observation cells or being transferred to a psychiatric institution. While these latter concerns still need to be addressed (see discussion under recommendation 151 and 152d) relevant information needs to be passed onto medical staff. The Coroner recommended:

4. Continuing efforts should be made to encourage prisoners to pass on concerns or information they may have that a fellow prisoner may be at risk either to custodial officers, Aboriginal Liaison Officers, or any other appropriate person.

In correspondence with this office, the South Australian State Coroner addressed the 'code of silence' among prisoners and stated:

...at risk behaviour is not brought to the attention of correctional officers because the consequences for the prisoner are perceived as negative. In my opinion, this could prove to be the single most important factor in dealing with deaths in custody. If this attitude can be modified, and appropriate protocols developed for dealing with prisoners who have been so identified such that co-prisoners will not be deterred from reporting, in my opinion the number of deaths in custody will reduce substantially.²¹

An increased level of trust between prisoners, correctional staff and health staff is the nub of this recommendation. Prisoners will always fear informers, but it should be possible to ensure that the culture of silence does not carry over into the medical arena.

Recommendation 152g
The development of protocols detailing the specific action to be taken by officers with respect to the care and management of:

i. persons identified at the screening assessment on reception as being at risk or requiring any special consideration for whatever reason.

ii. intoxicated or drug affected persons, or persons with drug or alcohol related conditions;

iii. persons who are known to suffer from any serious illnesses or conditions such as epilepsy, diabetes or heart disease;

iv. persons who make any attempt to harm themselves or who exhibit, or are believed to have exhibited, a tendency to violent, irrational or potentially self-injurious behaviour;

v. persons with an impaired state of consciousness;

vi. apparently angry, aggressive or disturbed persons;

vii. persons suffering from mental illness;

viii. other serious medical conditions;

ix. persons on medication; and

x. such other persons or such situations as agreed.

Recommendation 152g(ii) - Drug or alcohol conditions. There was insufficient information on drug or alcohol related conditions of prisoners and related protocols to draw any conclusions. In many cases it was a contributing factor in suicide (67NSW, 60SA and 33WA) and deaths from natural causes (46NSW, 57WA and 62NSW). In a number of cases it was clear that no protocol existed for dealing with the conditions (60SA, 33WA, and 57WA) while the protocol was not followed in the other cases (46NSW and 67NSW).

In two cases prisoners died from drug overdoses (10NSW; 56WA). In the former case the Coroner found that the deceased should not have been permitted to share a cell with another prisoner who was also a heroin addict. In the latter case the Coroner found that monitoring of inmates was sufficient and that further monitoring would lead to greater than necessary incursion on their liberty.

Recommendation 152g(iii) - Serious illnesses, particularly heart disease, epilepsy and diabetes. In several cases, Medical Service knew of illnesses but no action was taken as a result. In other cases the issue of protocols did not arise as prison medical services and prison officers did not detect the illness - see discussion under recommendations 154 and 155.

The man who died at Lithgow Prison (26NSW) had AIDS and diabetes, and the latter illness was extremely difficult to control. He needed to be placed in a shared cell due to constant fits but this did not occur at Lithgow Prison. In the case of the man who died at Long Bay Hospital (37NSW), the Coroner stated it was inappropriate to transport the deceased, who had heart disease, in a car to hospital.

In sentencing the man who died at Prince Henry Hospital (ex Cooma Prison) (44NSW), the Judge stated that prison authorities should give special attention to the deceased's cancer. The Coroner found that the authorities failed to take an x-ray in 1991 and that the deceased should have immediately been seen by a doctor when his condition deteriorated in February 1993. The Coroner found these omissions did not contribute to the deceased's death. In the case of the man who died at John Moroney Prison (46NSW), the Coroner recommended that staff should regularly monitor the anti-epileptic drug levels of epileptics to ensure they are in the therapeutic range. In the case of the woman who died at Mulawa Prison (62NSW) nurses and doctors failed to take appropriate action once they learnt of the deceased's endocarditis.

In the profile of the detainee who died in the Metropolitan Remand centre in Coburg, Victoria in 1993 (48VIC), the Coroner found irregularities in the procedures for dispensing epilepsy medication. He made no finding as to whether deficient recording of refusal to take epilepsy medication contributed to the death.

In the case of the man who died at Adelaide Remand Centre (78SA), the Coroner recommended that a series of protocols be developed to assist both medical and nursing staff to take appropriate action in urgent situations.

Recommendation 152g(iv) - Self-harm. The rapid increase in the number of suicides in prison requires a closer analysis of the deaths. Table 8.2a shows the number of self-inflicted deaths in prisons compare to the number of total deaths in prison.

In Queensland 81 per cent of prison deaths have been from suicide. In South Australia it is 56 per cent while in New South Wales and Western Australia it is respectively 26 per cent and 33 per cent. Comment cannot be made on trends in other States and Territories as there has been an insignificant number of deaths in prison.

Table 8.2a Suicide in Prison

The high numbers of self-inflicted deaths in Queensland and South Australia raises questions as to the development and effectiveness of protocols. Table 8.2b provides this information for the 21 cases where sufficient information on the circumstances of the death is available (coronial findings or legal submissions). The Table shows the number of breaches of this recommendation in each state and breaks them into three categories: (i) no protocol; (ii) protocol was unsatisfactory; and (iii) the protocol was not followed.

Table 8.2b Suicides in Prison: Protocols for Self-harm

In eight of the nine cases in Queensland there were no protocols for prisoners at risk of self-harm. In only five of these cases (14QLD, 34QLD, 45QLD, 64QLD and 74QLD) was this noted by the Coroner. Queensland coroners were restrictive in what they have looked at, but the issue falls squarely within their narrow scope.

In three cases it was apparent from the information available that no protocol at all existed (13QLD, 43QLD and 59QLD). In the remaining case of the juvenile who died at Lotus Glen Prison (22QLD) the deceased was given adequate care. He had the AIDS virus and was treated as a special case after petitions from the nurses at the prison.

However, it should be noted that in the case of the man who died at Arthur Gorrie Remand Centre (45QLD) the Coroner stated that 'steps had been taken to implement protocols for the care and safety of inmates' at the Arthur Gorrie Remand Centre. He commented that the introduction of such protocols would potentially benefit all prisons in Queensland.

The cases in New South Wales indicate the existence of such protocols, except for the early case of the juvenile who died at Maitland Prison (6NSW). However, coroners in three cases held that the protocol was not satisfactory. In the case of the 47 year old man who died at Parklea Prison (27NSW) the Coroner found that procedures were not followed because nursing staff withheld information from prison staff for reasons of confidentiality. In the case of the 24 year old man who died at Long Bay Prison (63NSW) the Coroner found that the system should be altered whereby: (i) prison officers are informed of prisoners are at risk; (ii) prison officers double check cells on let-go's for 'at risk' inmates who hide in the cells; and (iii) that sufficient resources should be allocated for this 'double checking' purpose. The unsatisfactory nature of the protocol in another case (72NSW) is discussed in conjunction with the Tasmanian case below. The protocol for prisoners at risk of self-harm was not followed in the case of the 19 year old man who died at Parklea Prison (67NSW). The reception nurse and Drug and Alcohol Worker did not properly inform prison officers as to 'risk status' of the deceased. Furthermore, the deceased was not visited by a psychologist despite a referral being made at the reception assessment.

The cases in South Australia and Western Australia raise issues concerning the satisfactory nature of protocols. In the cases at Yatala Labour Prison (60QLD, 68QLD) there were obvious hanging points (further discussed in recommendation 165) and in the earlier case infrequent checks of prisoners. In the case of the man who died at Greenough Regional Prison (33WA) the Coroner found that prison medical staff were justified in not classifying the deceased as 'at risk' despite the fact the deceased was placed in special 'at risk' observation clothing after returning from hospital. The Coroner found that the clothing was just a formality. However, this practice raises questions though as to the effectiveness of the procedure and leaves doubts as to whether officers regarded the deceased as being 'at risk.'

The cases of the 20 year old man who died at Long Bay Prison (72NSW) and the man who died in Risdon Prison (30TAS) raise the problems of re-classification. The former Aboriginal prisoner had attempted suicide twice within a week of imprisonment. After a week he was downgraded and put in a cell by himself where he committed suicide. Similarly, the latter prisoner was downgraded in the prison hospital from Category A to C and within 3-4 days he committed suicide.

In the profile A7QLD, involving a death in a mental institution, the investigation team made the recommendation that 'a buddy system be introduced in cases where a patient is at risk of self-harm.' This recommendation is the type which the Royal Commission contemplated.

Recommendation 152g(v) - Angry, aggressive and disturbed person. In three cases the deceased were overtly angry and aggressive (72NSW, 13QLD and 34QLD). Each had a history of mental illness. In another case the deceased was frightened and disturbed (68SA) but it is unknown whether the deceased suffered from mental illness.

In the case of the 21 year old man who died at Rockhampton Prison (13QLD) the deceased was hypersensitive. Notes on the psychologist's file indicated the deceased would react badly to violence. No procedures were put in place as a result. On the day of his death the deceased had two heated exchanges and struggles with officers who did not know of the deceased's hypersensitivity. This death triggered off further anger and unrest amongst inmates and was a contributing factor in the suicide of a Aboriginal prisoner the following day (14QLD).

The 17 year old juvenile who died at Sir David Longlands Prison (34QLD) was in a 'acutely disturbing' state. He was withdrawing from amphetamines, severely depressed and upset over an additional sentence preventing him returning home at Christmas. He had asked the senior psychologist for anger management counselling but this was refused. The deceased destroyed his cell on 17 December 1991 and committed suicide on 22 December. The Coroner recommended that Management Plans for young offenders be introduced.

The 20 year old man who died at Long Bay Prison (72NSW) had a personality disorder and was extremely abusive of staff. He was put in seclusion in an observation cell. He was later placed back in his own cell, when other suicidal prisoners needed to be placed in the cells. He subsequently