A design flaw in a cell door which had been reported seven years ago created a situation whereby a young detainee, aged in his 20s, could take his own life at the Alexander Maconochie Centre, a critical incident review has found.
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The review into the February 1 incident by the independent office of the Inspector of Correctional Services said the cell in which the young man was detained was being used as a Covid-19 isolation unit for all new receptions to Canberra's jail.
The risk posed by the design flaw had been identified and reported by facilities management staff in 2015 but had not been addressed by the-then AMC general manager.
The review found that the detainee had been properly assessed by mental health professionals on his admission to the prison. They found no indicators that he was at risk of self-harm or experiencing suicidal tendencies.
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The prisoner had taken steps to obscure the CCTV cameras in his cell around 5.20pm on the day of the incident. His body was discovered around 7pm.
The review by deputy Inspector Rebecca Minty has raised serious concerns about detainee safety, including concerns about the use of the restrictive environment in the management unit for COVID isolation.
Five recommendations have been made by the inspector's office
In summary, they are:
- to take immediate action to assess the unit's cell doors to comply with safety standards;
- written guidance for the ACT Ambulance Service for when they are called to the jail
- provision of a Hoffman knife to each custodial officer at the start of shift
- provision of an over-arching suicide prevention framework or strategy for the prison
- guidance for the operation of the Covid-19 unit, considering protective factors and prioritising detainee contact with the outside world
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