The mother of a man who killed himself in a cell at the Alexander Maconochie Centre has talked of her anger and her grief.
"Our beautiful baby boy Luke was only 27 years young when this horrific, life-changing incident was allowed to happen," Karen Reid told The Canberra Times.
She was speaking after an inquest into the death of her son Luke Rich at the ACT's prison. The coroner detailed serious flaws in the door of his cell - fatal flaws which the ACT government had been warned about.
A separate "critical incident" report after the death on February 1, 2022 found that the ACT government had not made the "urgent" changes "due to budget constraints".
"Luke was placed in a cell, left all alone for hours on end and without an opportunity to call me. He was left to his own thoughts and pain and given the tools needed to do the job of ending his life," his mother said.
"I have wanted to put Luke back in my womb. A place where he was totally protected by me and from the world and all its sin."
She thanked coroner Ken Archer and the lawyers from Ken Cush and Associates for the way her son's inquest was conducted.
The coroner said 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 Luke 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 said.
Apart from the coroner's findings, a separate "critical incident" report by the ACT Inspector of Correctional Services said that the "urgent" changes had not been made "due to budget constraints".
The coroner also found that the way prisoners were watched at the prison was "inadequate".
"Staff resources were insufficient to address the safety needs of detainees," he said. Staff 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.
ACT Corrective Services runs the ACT's prison. It is part of the ACT government's Justice and Community Safety Directorate (JACS). The Corrections Minister is Emma Davidson.
The ACT government said the coroner's findings would be studied. The doors had been changed. "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," an ACT Corrective Services spokesperson said.
Luke's mother was inconsolable. She said she was "constantly drowning in my heartache".
"My heart breaks every time I see a mum with her child and I have left family gatherings and friend's parties because I couldn't stop my sobbing and my heart breaks all over again being reminded of things that will never be.
"Luke will never marry. Luke will never be a father. I will never hold or caress Luke's baby or see the love and joy in his eyes as he holds his first-born child. I will never be hugged by the best hugger ever. The guilt I feel when I see my brother and my sister with their children and their grandchildren is breathtaking and heartbreaking."
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 detailing the "inherent safety risk". "The replacement of these doors has been deemed as urgent."
Mr Rich was arrested the day before his death. 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.
The cost of changing all the doors in the unit was put at $610,000 or $14,500 each for the 42 doors. Some were fixed - but not the one in Luke Rich's cell.
- Support is available for those who may be distressed. Phone Lifeline 13 11 14; beyondblue 1300 224 636.
