The Northern Territory coroner has given sobering insight into the rates of suicide in the Northern Territory, telling an inquest into the death of an Indigenous prisoner that the territory is in a "crisis".
WARNING: Aboriginal and Torres Strait Islander readers are advised that this article contains the name of an Indigenous man who has died, used with the permission of his family.
NT Coroner Elisabeth Armitage has spent five days, over two months, investigating the death in custody of Indigenous man Bernard Hector at the Darwin Correctional Centre in 2021.
The inquest has heard the 31-year-old died by suicide sometime between 11.11pm on August 29, 2021, and the early hours of the following morning.
By the time corrections officers found him alone in his cell, he had likely been dead for around eight hours.
"Sadly, and tragically, the Northern Territory has the highest, by far, death rate by suicide of any jurisdiction," Judge Armitage told the inquest today.
"There's been reporting recently in relation to an increase of suicide in Victoria [where] there's been a 9 per cent increase.
"From what I understand of the numbers, there has been a 25 per cent increase of suicides in the Northern Territory last year, over the previous year.
"This is a crisis of suicide for the Northern Territory, in my view."
Judge Armitage also said Aboriginal people took their own lives at a higher rate than non-Indigenous people and that there was a "confluence of factors in the Northern Territory" that contributed to the tragic statistics.
"I am taking it extremely seriously," she said.
"This is a problem that is not unique to the prisons, it's a problem across the territory; and because it's such a significant problem, every agency in the Northern Territory needs to take it seriously."
'No evidence' of mental illness
In closing submissions to the coroner today, counsel assisting, Kelvin Currie, said despite having a history of expressing thoughts of self-harm, Mr Hector was found in both 2015 and 2017 "not to be suffering psychosis or any other mental illness or mental disorder" after presenting to the mental health ward at Royal Darwin Hospital.
However, in 2021, Mr Hector was considered "at-risk" of self-harm when he was first remanded in custody, 52 days before his death, after telling his lawyer "I'm going to kill myself when I go to prison … tell my mum".
Mr Currie said Mr Hector's then-lawyer had told the Katherine Local Court the 31-year-old should be marked as an "at-risk prisoner" when he was jailed, but had not explained why.
"That is the first aspect where it seems the process could be improved," said Mr Currie.
"The Local Court procedure and form [should] be amended to make it clear that the information that a prisoner is at risk include the information leading to the opinion that they are at risk."
The coroner heard health staff who assessed Mr Hector at the prison, ultimately removing his at-risk status 24 hours later, were not made aware of the statement he had made to his lawyer.
However, the department's lawyer Michael McCarthy maintained the health assessment was correct and a multi-disciplinary team unanimously agreed that Mr Hector did not need to be considered at-risk.
"The court has heard that there were two persons who noticed a change in Mr Hector in the period prior to his death," Mr McCarthy said.
"Others at [Darwin Correctional Centre], including his cousin, did not … He was noted to be 'getting along well with others' … and 'joking and laughing' the day prior to his death."
The coroner heard the two people who did notice a change in Mr Hector had found him playing with a homemade Ouija board and claiming he had "sold his soul to the devil", but did not raise the alarm with health or corrections staff.
Mr Currie urged the coroner to recommend Aboriginal Mental Health First Aid training be made available to all prisoners.
"Those prisoners will be released back into the community, where there is a crisis within the Northern Territory," Judge Armitage said.
"If prisoners are coming out with those skills … that might have a flow-on effect."
Missed health appointments at prison
The coroner heard Mr Hector missed a series of follow-up health appointments at the prison, in the midst of COVID-19 lockdowns and restrictions.
After his first follow-up appointment on July 19 was rescheduled, Mr Hector did not see a nurse until August 25, when he was given a COVID-19 vaccine.
On that occasion, he was noted to be "alert and cooperative".
At an appointment with the alcohol and other drugs team on August 10, Mr Currie told the coroner that Mr Hector was found to be "relaxed" and said, "he sometimes felt a bit down but that he had no thoughts of self-harming".
Mr Currie urged the coroner to ultimately recommend the commissioner of Correctional Services "ensure that prisoners are able to, and attend, all appointments made with health services".
'We want to do better': Coroner
The barrister for Mr Hector's family, John Lawrence SC, made blunt and passionate final submissions to the coroner, telling the court the family were "dissatisfied" with the treatment of the 31-year-old.
"They still feel wronged about what happened to Bernard in those six weeks, and what didn't happen, and what could have happened," said Mr Lawrence.
"They ask, what went wrong?"
Mr Lawrence told the inquest he "thoroughly disagreed" with any notion that the investigation into Mr Hector's death was "comprehensive", but did not specify an area which was lacking.
Judge Armitage closed the inquest by directly addressing Mr Hector's family, telling them she would like to "try and improve things".
"It's not possible to save everybody, but we can have safer systems," she said.
"I know that you have other family members in the system, and you're worried about all of them … we want to do better for all your family members."
Judge Armitage will hand down her findings and recommendations at a later date.
