In the harsh light of his cell, alone and near death, Simon Cartwright pressed the intercom.
Water, he pleaded. He needed water.
“Please, please, just give me a chance, please,” he said, according to call logs provided to the coroner.
On the other end of the buzzer, the prison guards were getting irritated.
They’d shut off the water to Simon’s cell deliberately.
It was being used as a bargaining chip, an inquest would later find, by guards who had a limited understanding of his severe and untreated mental illness.
Simon begged for water 19 times before he died.
“Yeah, this is really entertaining actually,” a guard joked after one of Simon’s frantic pleas. “Yeah, keep buzzing up actually – this is keeping me entertained.”
They found Simon the next day, naked on a mattress in the middle of his cell.
He was cold to the touch. Despite being in an observation cell designed for 24/7 surveillance at Sydney’s Silverwater jail, rigor mortis had set in by the time anyone realised he was dead.
A nurse who had rushed to the cell, responding to a request for medical assistance, wrote in her report that Simon had been dead for a “prolonged period”.
His death was needless, a coroner would find. He was suffering from chronic peptic ulcer disease and had an ulcer in his small intestine.
It was highly treatable. A drug called pantoprazole, administered at any point before the 25th day of his 30-day stay in Silverwater, would most likely have saved him, according to a gastroenterologist expert witness.
But prison staff inexplicably missed all signs pointing to serious illness.
Simon was extremely thin, to the point of malnourishment, and was recorded on CCTV clutching himself in pain and collapsing to the ground, although this was not observed by guards. He told guards he was struggling to breathe.
Prison health staff had failed to make even a cursory check of their own records. Those records showed he had a history of gastric ulcers, infection and vomiting blood. Instead they wrongly answered “no” to a prompt of “history of gastrointestinal conditions?” during Simon’s intake assessment.
The untreated ulcer penetrated surrounding organs in the weeks that followed, according to autopsy notes provided to the inquest. Bacteria entered Simon’s bloodstream and he went into septic shock, dying sometime on 19 September 2021.
His grieving family have spent the years since trying to find answers. Their journey has led them to an incontrovertible truth – one that sits at the foundation of everything that went wrong.
Simon should not have been in Silverwater. He should have been in hospital.
Sixteen days before his death a psychiatrist had invoked the state’s mental health laws to order Simon be transferred to hospital for treatment for his unmedicated schizophrenia and bipolar disorder.
No bed could be found, something the coroner would describe as a “gross systemic failure”.
He was locked up for a month in a cell designed to be used for no more than 48 hours, and mocked by guards who withheld water from an emaciated man as punishment for behaviour they did not understand.
“It was torture,” Simon’s sister Clare tells Guardian Australia.
A mother’s premonition
In her hospital bed at Lingard Private, in the beachside Newcastle suburb of Merewether, Simon’s elderly mother, Frances, had reason to smile.
It was her birthday, 20 September 2021, and two of her three daughters, Michele and Alison, had just turned up. She thought they had managed to bypass Covid restrictions to pay her a surprise birthday visit.
One look at their faces changed her mind.
“I thought they had been given special permission as visitors were not allowed,” Frances wrote. “However, on closer look realised they were to give me bad news and I immediately knew it was Simon – a mother’s premonition.”
At that stage, Frances didn’t even know her son had been in prison. None of his family did.
Alison was the first to find out. Police officers told her about her brother’s incarceration when they knocked on the door of her Gosford home to tell her he was dead.
The next day she and Michele travelled north to see their mother. The sisters could offer no explanation of what had happened.
“That was the worst thing I have ever had to do,” Michele says.
It was the beginning of a never-ending period of grief for Frances.
The news triggered a desperate search for information. It was not forthcoming. The New South Wales government took months to release details.
In December Justice Health, which runs health services at NSW correctional facilities, briefed the family on the results of its internal serious adverse event review.
This raised more questions than it gave answers. The family wanted to know, among other things, why there were huge stretches of “unaccounted” hours where no recorded observations were made of Simon, and why more wasn’t done to investigate his physical health.
Frances wrote a furious letter to the then corrections minister, Geoff Lee. She described her son’s treatment as worse than that of a dog. She asked for a more thorough investigation.
“To be told that Simon had been found dead at 8pm on the 19th was one of the worst moments of my life,” she wrote to the minister on 27 January 2022. “Just thinking of Simon dying all alone with no family was unbearable.”
She received an automatic receipt, promising the minister would respond within 28 days. When the 28 days passed without reply, Frances sent the letter again.
She received nothing back.
Smart, bright and loved to dance
Simon was a smart kid, his sisters agree. They remember a child who loved music and loved to dance.
He grew up in Tamworth, the youngest of six children. His closest sibling was 10 years his senior.
Frances always told the kids it made raising Simon a dream. She had five pairs of hands eager to help.
“He was a gorgeous little baby who everyone spoiled from day one,” Clare tells Guardian Australia. “He was a really loved kid. And he was very smart, probably because he had all his siblings pushing him along. He was bright, really friendly, outgoing social boy.”
Things changed in his teenage years after he began using cannabis.
“It just changed him, it changed the way he looked at life,” Clare said. “Keeping him at school was difficult, he just struggled.”
The strain on his parents became overwhelming.
His siblings tried to help. At one point Clare brought him up to the Gold Coast for rehab. She lost count of the times the family set him up in an apartment, furnishing it for him, and hoping for stability.
“I don’t know what the percentage was of good to bad,” she said. “But there were lots of years where he was stable and he was still, sometimes, mentally challenged with his emotions.”
In 2008, at age 28, Simon was diagnosed with schizophrenia and in 2013 he was diagnosed with bipolar disorder.
When his parents moved from Tamworth to Wollongong, Simon followed, getting a unit in a public housing estate.
“The move to Wollongong was the start of some more serious times when he was in a mental health hospital and then back out,” Clare said. “Then the cycle of good and bad would begin.”
In July 2020 a new psychiatrist at Shellharbour hospital abruptly departed from the decade-long diagnoses of schizophrenia and bipolar disorder, reclassifying Simon’s condition as a personality disorder and polysubstance use disorder.
The antipsychotic medications he had been taking for years were discontinued.
Simon’s longstanding psychologist expressed concern about the sudden change.
Records tendered to the inquest show the psychologist warned that Simon would become a problem for police and “potentially could go to gaol” if his psychiatric condition was not properly managed.
That prediction was realised just six months later.
In January 2021 Simon lit a fire in a neighbour’s apartment and was remanded briefly in Silverwater.
At that point, prison staff noted his history of gastric ulcers and infection, vomiting blood and weight loss, obtaining records from two hospitals that had treated him. They had prescribed pantoprazole.
All of these records would be available to prison health staff seven months later, when Simon returned to Silverwater.
After 13 days on remand, the court deemed him not criminally responsible for the fire, due to his serious mental ill health, and sent him for treatment at Cumberland hospital in Parramatta.
Discharge notes handed to the inquest suggest the treatment was effective.
“On assessment at the day of discharge, Simon was well-kempt, polite and co-operative,” they read. “Engaged well and maintained a good eye contact. Speech was well articulated, coherent with normal rate, rhythm and tone. Did not exhibit any psychotic or pervasive mood symptoms.”
Clare said her brother often responded well to treatment. It made him stable and able to spend time with the rest of the family. It gave them hope.
He’d come to Christmases and weddings. He’d help Frances with her vacuuming. She’d do his washing.
“He was good for long periods of time but that was on medication,” she said. “The medication had bad side-effects, so he’d self-medicate or come off the medications, and then the cycle of getting into trouble [would begin again].”
Return to Silverwater
On 19 August 2021 Simon was sent back to Silverwater.
He’d been arrested on relatively minor charges of trespass, intimidation and resisting arrest.
On 3 September a psychiatrist used the state’s mental health laws to order Simon be transferred to Long Bay forensic hospital, 40 minutes across Sydney, for involuntary treatment.
“Care of an appropriate kind is not available in a correctional centre as he is refusing treatment in this setting,” the psychiatrist wrote.
Experts told the inquest that, had such an order been made for someone in an emergency department, they would generally receive appropriate treatment within four hours.
Delays of more than 24 hours would be rare. Delays beyond two days would be regarded as a significant failure of the system.
There were no beds left at Long Bay. Simon languished in a queue for weeks.
On 7 September he was still behind eight others waiting for a bed.
A week later he was second on the list for transfer. Five days later he was still stuck at Silverwater.
The inquest was told the delay was “unimaginable in Australia”.
The deputy state coroner, Erin Kennedy, found that, had Simon been transported to Long Bay, his physical health would have been more closely monitored and the ulcer would probably have been detected and treated.
Instead he was kept in his cell alone.
It was, in the words of one psychiatric expert, a torture-like setting for a man suffering untreated schizophrenia and bipolar disorder.
The lights never went out.
The surfaces were hard and cold.
The noise and chaos spilling in from Silverwater’s Darcy wing was constant. The surveillance camera was always on.
Ordinarily, inmates are not held on the wing for more than 48 hours. Simon was there for almost a month.
At times, Simon was recorded as being doubled over in pain. He collapsed to the floor repeatedly.
For long stretches he sat with his head in his hands. Guards reported him muttering “biblical things” they couldn’t understand.
Transcripts of his intercom exchanges show a man confused and afraid.
“You have to understand I’m struggling to breathe,” he told the guards the day before he died. Five minutes later, he buzzed for help again.
“Yeah, um, sorry, just give me a sec, I’m standing in front – just give me a few minutes to breathe,” he said.
A guard responded: “You’re not doing yourself a favour. Just go to sleep.”
Clare and her family have watched the CCTV recordings and listened to the intercom exchanges of Simon’s final days. She says these will stay with her for ever.
“He must have been in so much pain to die of sepsis in the last 48 hours, to be so unwell and to be refused water, just the basic human need of water,” she said.
“It’s just, it can’t be comprehended.”
Clare counted the 19 times that her brother pleaded for water over two days.
Guards had shut off the water after Simon left a tap running, flooding the cell. On the evening before his death one told him they would give him water if he stayed silent.
“Cartwright, is that you?” the guard asked. “Cartwright, listen. If you be quiet for half an hour and stop knocking up I’ll turn the water on.”
Simon waited an hour and a half then rang again.
“What is your 300th medical emergency for the night?” the guard responded.
Simon pleaded: “Can you turn the water on!”
The guard said: “If you aren’t knocking up so much I’ll do it.”
Simon begged: “Please!”
The last request for water came at 7.48pm.
“Medical?” the guards responded.
Simon again asked: “Can you turn the water on please?”
The guard said: “If you don’t behave like that we will.”
The voice in the recordings was barely recognisable to Simon’s family.
“It was just so strained and pleading and begging,” Clare says.
The prison had no formal policy or procedure governing the restriction of water to cells, the inquest found.
Sometime in the year of Simon’s death, a requirement was introduced that compelled guards to get approval by a manager and document such a decision in an accommodation journal.
There is no evidence that the requirement was in place at the time of Simon’s death.
‘Why are we burying him? We don’t know why’
Simon had not been convicted of any crime. He remained innocent in the eyes of the law.
Even if he were convicted, the inquest heard, there was little indication he would have been sentenced to imprisonment. He could have been diverted for mental health treatment and sent to a hospital by the courts, as had happened previously, or given a non-custodial sentence.
He was by no means a hardened criminal.
“He was one of the most vulnerable in our community,” the coroner wrote.
Clare has a vivid memory of her brother’s funeral.
He was laid to rest in Newcastle.
Covid restrictions meant Clare could not get across the Queensland border. She was forced to watch a video stream.
On it she saw her mother sitting on her own, weeping.
Frances was forced to grieve alone, separate from the rest of the family, because of social distancing rules.
“Seeing my mum just sitting there hunched over on her own, sitting on her own, not even having someone sit next to her and hold a hand – it’s just the most memorable thing in my mind,” Clare says
The family still knew little about what had happened. It robbed them of any semblance of closure.
“You know, we’re burying our brother and we’re like, ‘What happened?’” Clare says.
“You know, you can’t say farewell when there’s just questions in your head: ‘Why are we burying him? We don’t know why.’”
Clare was dealing with trauma of her own when she found out her brother was dead. Her husband had been diagnosed with pancreatic cancer.
Between treatments, the couple jumped in a caravan and hit the road. Clare described their trip through the outback as “a bucket-list thing”.
They got as far as Julia Creek in north-western Queensland when Clare’s sister called.
“It’s almost numbing – you just don’t expect to get that call about your siblings,” she says. “Especially our youngest brother. In the back of your mind for so many years, you’re thinking, ‘is Simon going to get better and get himself on his feet or one day are we going to find out that something has happened to him, or he’s disappeared?’”
“It was just this feeling of total numbness, the shock that one of us had passed away out of the six of us.”
‘Cartwright, wake up’
The CCTV camera in Simon’s cell captured several distressing scenes the day before his death.
On three occasions he collapsed to the floor. The first time he stumbled and fell backwards over his toilet, remaining on the ground for two minutes.
Three and a half hours later he fell while walking towards his bed. He stayed on the ground for two minutes.
An hour and a half later he stood up from the bed then fell backwards. He fell again while trying to get to his knees, this time lying on his side for five minutes before getting up.
No one in the jail noticed, the inquest found.
“You don’t need to be a medical person to see how much pain he was in, anyone could see just how much he was suffering,” Michele says. “His whole experience in the facility by those who were supposedly looking after him was inhumane.”
About 9pm that evening, Simon covered his cell’s CCTV camera.
Staff testified that steps are usually taken within an hour to uncover surveillance cameras.
It took three shifts and almost 24 hours for the camera to be uncovered.
Physical checks of the cell were not much better.
On the day of Simon’s death, CCTV recordings showed the guard on duty looking into the cell for about four seconds at 2.17pm. He didn’t stand outside the cell and look in again for five hours.
The guard used the intercom about 3.41pm to ask Simon to uncover the camera. He received no response.
About two hours later, he tried again: “Hey, mate, 37. Cartwright. Cartwright, wake up.”
Again, there was no response. Nobody bothered to conduct a physical check.
“Although in ostensibly a 24 hour surveillance cell, he was in fact not being observed, nor indeed observable, 24 hours a day,” the coroner wrote. “In the days leading up to his death no one identified that Simon was in fact in urgent need of medical attention. His falls were not observed, his weakened state was not investigated.
“The seriousness and urgency of his condition was missed.”
After Simon’s death was discovered, the guard on duty filled out an observation form that wrongly suggested that electronic observations had been conducted at 30-minute intervals, the inquest found.
The guard later accepted that the form was “not an accurate representation of his observations”. He said he had created the document in an attempt to “neat up” a scrappy piece of paper he had been using to record his checks on Simon.
He also made “misleading” statements about his physical checks on Simon, which he later accepted as being “false”.
The inquest found that, even with proper checks on that final day, Simon may not have survived.
“The fact that Simon lay dying and dead on a cell floor, for long enough that he was not found until there were clearly no indications of life, despite supposedly being subject to the highest level of monitoring within the gaol, is both alarming, and carries its own particular trauma for Simon’s family,” the coroner found.
‘Haunt us forever’
Simon’s mother waited almost three years for an inquest into her son’s death.
The family felt it was their only real avenue to the truth.
Frances, a pensioner, tried to obtain legal aid so they could be represented in the coronial process but was rejected. It was a decision that infuriated them.
They travelled to Sydney for the hearings in May and August this year.
They sat in the courtroom, despite invitations to leave, as Simon’s last moments were played to the court, and then prepared a moving statement for the inquest:
We are changed forever by the circumstances surrounding his death. Beyond the lack of health care provided the fact that a staff member unilaterally chose to deny Simon water after multiple pleading requests is appalling and a disregard for his basic human rights.
We can only regret the many missed opportunities to save him and the thought of what he would have suffered will haunt us forever.
The statement was repeated, almost in full, in the coroner’s concluding remarks.
Her findings were delivered this month. They are damning.
Kennedy found that Simon could have been saved. She was highly critical of the decision to withhold water from him.
“Simon’s death was preventable,” she found. “This inquest highlights that [Corrective Services NSW] is not and should not be placed in a position to care for a mentally ill person. Once Simon was scheduled arrangements should have been made to provide medical care.”
She recommended that guards on duty be told the reason that inmates are placed in observation cells. She said it was “unfair” that guards were not explicitly given this information, but accepted that it was available to them if they looked for it.
She recommended that formal policies be implemented to govern the practice of restricting water to cells and to ensure that prisons monitor food and fluid intake.
Justice Health was told to “give consideration” to recommending transfers of mentally unwell patients to external hospitals when no beds at a designated facility are available.
The coroner recommended mandating mental health first aid training to officers staffing observation cells. She also recommended that guards be told at the start of their shifts why each inmate is in an observation cell.
Justice Health said it acknowledged the pain caused by Simon’s loss and extended its sincere condolences to his family.
“We are sorry for the distress experienced by Mr Cartwright’s family and will carefully consider the coroner’s findings and recommendations before providing a formal response to the attorney general,” a spokesperson said.
A spokesperson for the current corrections minister, Anoulack Chanthivong, said the death was a “tragic loss” to Cartwright’s family and loved ones, and said “we offer them our deepest sympathies”.
Corrective Services NSW’s formal response to the inquest will be released at a later date.
But the spokesperson said a number of reforms have already been implemented since Cartwright’s death, including establishing a specialised observation suite at Silverwater’s remand centre to monitor at-risk inmates electronically; updating observations policies for at-risk inmates; and implementing a mandatory requirement for control room officers to document and record emergency response activities.
Corrective Services is also trialling a new proof of life monitoring technology to detect vital signs, including heart and respiration rates. It has commenced a review of its policies regarding the restriction of water to prison cells.
It will also aim to improve its supervision of inmates held in assessment cells for more than 48 hours and is investigating further mental health training for guards.
“Corrective Services NSW takes seriously its duty of care to inmates who they are tasked with keeping safe and secure while under supervision,” the spokesperson said. “Any conduct that jeopardises the health or wellbeing of inmates or staff is completely unacceptable and inconsistent with the extremely high standard of behaviour that the minister expects.”
“Corrective Services NSW will follow the expert advice of Justice Health in respect to the clinical management of inmate physical and mental health issues, and placement in specialised mental health beds.”
It is understood the Corrective Services NSW professional standards unit is also assessing the inquest report to determine whether to take action.
The coroner’s findings have come too late for Frances. She died last month at the age of 87, about two weeks before the decision was handed down.
“My mother was always at the forefront of finding out what happened to Simon,” Clare says. “Her grief was endless and her regular questions and follow-up with me ensured that we wrote a response to the initial [serious adverse event review] report.”
Clare says the inquest has given the family a partial sense of justice. They have nothing but praise for the police investigation and the crown lawyers who worked to find out what had happened.
But she says she feels like there have been no real consequences.
“It feels like a bit of a slap on the wrist, you know, that they’ve been told that they probably should do things better,” she said. “But really, is that enough when they’ve let someone die in those circumstances?
