A potential document "oversight" may have contributed to the death of an inmate, an inquest has heard.
Justin Cordy was 34 when he died from a suspected suicide while in custody at the Alexander Maconochie Centre on February 26 last year.
During a hearing in the ACT Coroner's Court on Monday, two A4 pictures of Justin, captured while smiling dressed in a suit, were placed either side of the room.
Coroner Lucinda Wilson said the inquest would "focus on the last days of Justin's life".
The coroner stated she would be required to make findings about his quality of care and treatment, as well as any matters of public safety.
"[His death] represents a tragedy for the family, for his loved ones, for his friends," Ms Wilson stated.
"I am not sure if this inquest is going to find a clear reason why Justin did what he did ... we are here to find the truth and make recommendations."
'Focus on the last days of Justin's life'
Counsel assisting the coroner, Vanessa Thomas, outlined the days leading up to the 34-year-old's death.
On February 21, 2023, Justin was released on a good behaviour order after spending five months behind bars.
Two days later, police were searching for the man following domestic violence allegations but he could not be found.
Police paperwork for these allegations contained "a minute" recommending the Office of the Director of Prosecutions consider applying for the court to order Justin be sent to a mental health institution to undergo an assessment.
However, police were not able to find him until the next day when he is said to have rammed a police car with a stolen vehicle.
Ms Thomas stated Justin later crashed that vehicle, before running off on foot, and brandishing a knife outside numerous homes in Chisholm.
He was allegedly holding the knife in a gesture threatening self-harm when police Tasered and arrested him.
Later that day, he was taken to hospital by police but discharged shortly afterwards.
Separate police documents, relating to the second series of allegations, did not recommend Justin be sent for a mental health assessment.
While at the watch house, he asked to speak to a mental health clinician but, after an eight minute discussion over the phone, a nurse found he had no current suicidal thoughts.
Potential 'oversight'
On February 25, 2023, Justin was due to face ACT Magistrates Court.
Ms Thomas said it "appears that due to an oversight" documents emailed from a prosecutor to a Legal Aid duty lawyer did not include the minute recommending a mental health assessment.
Two bail consideration forms were attached in the email: one recommending an assessment, and the other stating it was "not applicable".
Justin was said to have asked his duty lawyer about speaking to a mental health expert, but was informed the service was not available on Saturdays.
Ms Thomas told the court the Legal Aid lawyer advised Justin he could apply to be taken to a mental health institution, but he declined.
He later appeared in court before magistrate Ken Archer, the ACT's first dedicated coroner, and did not apply for bail. Ms Thomas said there was no mention of a mental health order.
He was then taken to Canberra's jail, where he underwent a mental health and primary health assessment.
A nurse noted a prior suicide attempt while Justin was in jail in 2020, but the inmate denied current thoughts or plans for suicide.
It was recommended corrective services officers check on him hourly.
He was housed in the special care centre within the jail, a separate section designed for prisoners with more needs.
On the day after he was admitted to jail, a corrective services officer checked on Justin in his cell around 11.40am.
It was practice at the time that inmates were locked in their cells from 12pm to 1pm while staff had their lunch hour.
According to CCTV footage, an officer next checked on the prisoner at 1.03pm when he was found dead from apparent suicide.
The hearing, set to run for 10 days, continues.
- Support is available for those who may be distressed. Phone Lifeline 13 11 14; MensLine 1300 789 978; Kids Helpline 1800 551 800; beyondblue 1300 224 636; 1800-RESPECT 1800 737 732.
