Prison guards switched off the water to the cell of a mentally ill and dying man as punishment for his strange behaviour, joked that his repeated pleas for help were “entertaining”, and then left him unobserved to die at Silverwater jail from a treatable illness that was inexplicably missed.
The litany of failures that led to the preventable death of Simon Cartwright, a beloved brother and son, highlight the chronic under-resourcing of Australia’s secure mental health facilities and the dangers of using prisons to hold those suffering severe mental ill health, a coroner has found.
The case also reveals callous treatment of Cartwright’s grieving family, who did not know he was in custody until after he died, were not told by Justice Health or Corrective Services about the circumstances of his death for months, and were then ignored by the office of the former New South Wales corrections minister Geoff Lee when seeking answers.
The family is now taking legal action against the NSW government and has called for urgent reform.
“I just cannot believe this can be done,” Cartwright’s sister, Clare, told Guardian Australia. “To be so unwell and be in so much pain and to be refused water – just the basic human need of water – it’s just, it can’t be comprehended.”
Cartwright was suffering schizophrenia, bipolar disorder and chronic peptic ulcer disease, a treatable condition, when he was arrested on relatively minor charges and held in the remand centre at the Silverwater prison complex in August 2021.
The severity of his mental ill health was such that, 16 days before he died, psychiatrists used the state’s mental health laws to order he be sent to the Long Bay forensic hospital, a secure facility about 40 minutes’ drive from Silverwater, for involuntary treatment.
But, the coroner heard, a lack of beds at Long Bay meant he was instead kept alone in an observation cell at the prison, where he was supposed to be under 24/7 video surveillance and 30-minute observations by patrolling guards.
No bed became available before Cartwright died in Silverwater prison on 19 September 2021, something a coroner this month described as a “gross systemic failure”.
Cartwright’s mental illness made him a highly vulnerable prisoner. The inquest into his death described him as “one of the most vulnerable in our community”.
The cell in which Cartwright was held was described by one expert as a setting of “mental illness torture” because it was lit constantly, even through the night, only had hard surfaces and appeared cold, loud and chaotic. He had only a gown, blanket and thin mattress.
Cartwright was behaving erratically. Prison staff recorded him muttering about “biblical things … that did not make sense”.
He was also extremely physically unwell. Recordings showed the 41-year-old was emaciated and shuffled around like an old man, often bent over and hugging his stomach protectively.
He collapsed suddenly a “significant number of times”, including three separate times on the day before his death, the coroner found. The falls were all missed by prison staff.
At some points he appeared to be doubled over in pain. At other times he sat on the floor of his cell with his head in his hands.
Prison health staff inexplicably missed the fact that Cartwright was suffering from a life-threatening gastric ulcer disease, something that likely would have been discovered upon a review of records from a previous admission to Silverwater seven months earlier.
Cartwright probably would have survived had he been given the drug pantoprazole anytime before 14 September, five days before his death, according to a gastroenterologist who gave evidence at the coronial inquest.
He received no medical attention or help. Had he been transferred to Long Bay on 3 September, as intended, staff at the hospital would likely have discovered the ulcer and treated him appropriately, the coroner found.
Instead, guards turned off the water to his cell.
Initially, this was done because Cartwright had left a tap on, causing the cell to flood. But the denial of water continued in the two days before his death. Guards used it as a tool of coercion and punishment, designed to force Cartwright to “behave”, the coroner wrote.
Cartwright made 19 separate pleas for the water to be turned back on through the prison’s intercom.
Logs of his exchanges show he repeatedly pleaded for the water to be turned back on, at times becoming frantic.
The guards repeatedly refused to do so unless he “behaved” and stopped using the intercom. The coroner found the officers “had a lack of awareness of the nature and severity of Simon’s mental health issues”.
“Yeah this is really entertaining actually,” one guard joked after a call in which Cartwright begged for water.
“Yeah keep buzzing up, actually this is keeping me entertained.”
At one point, Cartwright was told the water would be restored if he kept quiet for 30 minutes. He waited an hour-and-a-half and buzzed again for help.
The guard responded: “What is your 300th medical emergency for the night?”
Cartwright said: “Can you turn the water on?”
The guard responded: “If you aren’t knocking up [calling for assistance] so much I’ll do it.”
Cartwright responded: “Please!”
Cartwright’s family listened to recordings of those intercom exchanges during the inquest into his death.
His sister, Clare, said it was something they would never forget.
“It was horrendous,” she said. “It will take a long time for me to forget that sound of his voice.
“It was just so strained and pleading and begging.”
Cartwright died alone at some point on 19 September.
The coronial inquest into his death heard that the prison failed to properly observe him.
Despite being in a 24-7 surveillance cell, his body was not discovered until rigor mortis had set in. Before his death, staff did not remove material Cartwright had used to cover the cell’s camera for almost 24 hours, leaving it obscured across three separate shifts.
The material should have been removed from the camera with an hour, senior prison officials told the inquest.
They had also failed to conduct proper physical observations of him.
After his death, the guard on duty created a new observation form to enter “false or misleading information” suggesting electronic observations were being conducted of Cartwright at 30-minute intervals, the coroner found.
The same guard conducted only “cursory” glances to check on Cartwright on the day he died, left a five-hour gap between physical observations, and later gave evidence about his efforts that was “misleading” and conflicted with CCTV recordings.
“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 jail, is both alarming, and carries its own particular trauma for Simon’s family,” the coroner wrote.
A spokesperson for the NSW corrections minister, Anoulack Chanthivong, said the government acknowledged the inquest findings and expressed deepest sympathies to Cartwright’s family.
“Mr Cartwright’s death was a tragic loss to his family and loved ones, and we offer them our deepest sympathies,” the spokesperson said. “We will be carefully reviewing all recommendations and thank the Coroner for her thorough examination of the issues leading to Mr Cartwright’s death.”
Cartwright’s family have spent years fighting for answers. They were initially told nothing about the circumstances of his death and buried him without knowing why he had died.
After a briefing from Justice Health in December 2021, Cartwright’s mother, Frances, wrote to Lee, a former corrections minister in the previous government, demanding a more thorough investigation.
The grieving mother said her son had been treated worse than a dog.
“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.”
Her letter received no reply from Lee’s office.
She followed up again after 28 days – the standard wait time for ministerial replies – and again received no response, either from the minister’s office itself or any department or ministerial colleague responding on his behalf.
She then died before the deputy state coroner handed down her findings earlier this month.
“Simon’s death was preventable,” the coroner 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.”
Do you know more? Email christopher.knaus@theguardian.com
