- Inquest, day one: At-risk inmate moved into isolated cell, left alone before suicide
- Inquest, day two: Poor information sharing, overcrowding were problems in prison suicide
- Inquest, day three: Health ward was appropriate place for inmate
- Inquest, day four: Prison worker denies health ward where inmate suicided was 'isolated'
The transfer of an inmate with mental health problems into an isolated, dangerously designed ward "contributed" to his suicide, a coroner has found.
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The detainee's death occurred just one month after he was remanded in custody in mid-2013.
The prisoner had a history of mental health issues and suicidal thoughts, and was marked as an "at-risk prisoner", prompting a regular regime of observations and review.
The inmate was placed in the prison's 10-bed crisis support unit, which is specifically designed for those at-risk of self-harm.
Coroner Bernadette Boss, who examined the death extensively in a four-day hearing earlier this year, found the inmate was cared for, assessed, and reviewed appropriately.
But about three weeks later, the prison's High Risk Assessment Team found his improving condition made him eligible to move out of the crisis unit.
The inmate had no immediate plans for suicide and was only hearing "soft whispers" in his head.
He was still telling nurses and psychiatrists that he wanted to die, and would likely kill himself in two to three years.
On the day of his death, a psychiatrist had found him to be a moderate to high risk of suicide in the longer term, but a lower risk in the short term.
He was moved out of the crisis unit and into a health ward, used as a medical treatment room for Alexander Maconochie Centre detainees.
His room was isolated from other parts of the AMC.
Staff rarely walked past, and it was removed from other cells and detainees.
There was no television to help the inmate ignore voices, and staff could not easily see into the room's ensuite from outside.
That ensuite had an extendable hose fitting for the shower, an obvious hanging risk.
The inmate was placed on a 60-minute observation regime.
One of the nation's leading forensic psychologists, Professor James Ogloff, gave evidence to the inquest that that observation regime would have done little to prevent self-harm.
Professor Ogloff also found aspects of design of the health ward was "quite alarming" and inappropriate for someone displaying symptoms of a mental ilnness.
Dr Boss agreed with Professor Ogloff.
She found the health ward did not directly cause the death, but that the various problems with its design contributed to the suicide.
"I find these combined circumstances contributed to [the prisoner's] death," Dr Boss found.
The coroner found the inmate, despite improvements in his condition, still posed a "discernible risk that needed to be catered for".
Despite that, Dr Boss found the ward he was sent to was not audited or assessed for its suitability to take inmates who may pose a self-harm risk.
"[The inmate] was the sole focus of attention, not his environment," Dr Boss said.
Dr Boss found he was properly assessed and reviewed by the multidisciplinary team operating inside the prison, the High Risk Assessment Team.
She made no adverse findings against any individual.
The government was already engaged in a significant overhaul of the way it treated at-risk inmates at the time of the death.
Dr Boss recommended on Friday that ACT Corrective Services engage an expert to look at its management of at-risk inmates to assess the changes that have been implemented.
She praised ACT Policing's investigation of the death, joining with a psychiatrist who said it was the most comprehensive collection of information he had seen in such a case.
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