A coroner has severely criticised the ACT government for putting a prisoner who died by suicide into a cell that it had been warned was unsafe.
The inquest into the 2022 death of Luke Rich found that a design flaw in doors at the Alexander Maconochie Centre had not been addressed even though the government department had been warned of its dangers.
Apart from the findings by the coroner, a separate "critical incident" report into the death by the ACT Inspector of Correctional Services said that the "urgent" changes had not been made "due to budget constraints".
At the conclusion of the inquest, coroner Ken Archer found that "at the time of Luke's death, the territory chose to accommodate newly arrived detainees in a physical environment they knew to be, in one important aspect, unsafe.
"The rear doors of the management unit (where Mr Rich was incarcerated) were known to be used as a ligature point for those detainees minded to committing acts of self-harm. In 2020, they had been identified as needing urgent replacement. They were not replaced."
The coroner also found that "the observation regime in place was inadequate".
"Staff resources were insufficient to address the safety needs of detainees. Staff members with responsibility for caring for Luke were not briefed as to Luke's mental health history, and known risks associated with the physical environment in the management unit cells," the coroner said.
The coroner also found that staff at the prison relied on CCTV to keep an eye on prisoners "because of a lack of staff resources".
"Luke rendered that form of observation ineffective by placing a sticker over the lenses of cameras located in his cell and in the yard. That practice was common amongst experienced detainees," the coroner's findings said.
"Observations were poorly recorded in a form that was tolerated, if not officially condoned, by ACT Corrective Services ("ACTCS") management."
ACT Corrective Services runs the ACT's only adult prison. It is part of the ACT government's Justice and Community Safety Directorate. The Corrections Minister is Emma Davidson.
The government said it had been waiting for the inquest to finish before responding to the inspector's review.
An ACT Corrective Services spokesperson said: "Upgrades to the rear cell doors in the Management Unit were conducted in May 2022 to reduce the risk of the door bars being used as a ligature point in future."
"We acknowledge this sad loss for his family, friends and loved ones, and extend our sincere condolences to them," it said.
"We also acknowledge the officers and other frontline staff who responded quickly and professionally to provide assistance in these distressing circumstances."
Mr Rich was arrested the day before his death on February 1, 2022. There had been allegations of violence against his partner. In 2020, he had been arrested in relation to similar allegations against the same person, the inquest heard.
After the 2022 arrest, he was put in the ACT prison's management unit, which is usually reserved for particularly difficult or dangerous prisoners, but in this case it was used as a cell to isolate prisoners from each other during the pandemic.
His mental state was assessed but he was not judged to be a suicide risk.
All the same, he quickly detected the gap in the bar on his cell door and inserted a sheet through it to take his own life.
A "critical incident" report seven months after the death identified the ways in which the ACT government department had rejected warnings that the design flaw could be fatal.
The doors had been examined after a previous suicide attempt and a memo sent to the ACT government's Justice and Community Safety Directorate.
"Due to the inherent safety risk identified with the current doors, the replacement of these doors has been deemed as urgent and needed within a timeframe that would not allow for a standard open market tender process," the government department was told.
The cost of changing all the doors in the unit was put at $610,000 or $14,500 for the 42 doors.
In the "critical incident" report into Mr Rich's death, the ACT's Inspector of Correctional Services said that not all the doors were replaced "due to budget constraints". The inspector said that he might have expected that it "would have been the priority" to replace the back doors, one of which Mr Rich later used.
The coroner made a series of recommendation at the end of the inquest:
- ACT Corrective Services should publish guidance for staff to improve the way prisoners are observed, particularly "what is to be done when cameras are intentionally covered by detainees".
- "External consultants be engaged to assess the safety of the rear doors in the management unit in light of the evidence in this inquest; and the outcome of that review be published."
- "A Suicide Prevention Framework for [Corrective Services] be developed as a priority."
The lawyer for the family, Sangeeta Sharmin from Ken Cush & Associates, said the recommendations should be "implemented by the ACT with urgency".
The directorate said the government would review the findings and recommendations.
"ACT Corrective Services has been active since this sad event and has already made changes to address issues that were identified following his passing. This will be detailed in the ACT government response," it said.
- Support is available for those who may be distressed. Phone Lifeline 13 11 14; Men's Referral Service 1300 776 491; Kids Helpline 1800 551 800; beyondblue 1300 224 636; 1800-RESPECT 1800 737 732;
