Indigenous Deaths in Custody: Chapter 8 Custodial Conditions

Part C - Profiles Analysis

It is totally unreasonable for police who catch the crooks to then be accountable for their welfare.

Western Australian Police Union Secretary,
after the death of an Aboriginal man at the East Perth Lockup, 1994¹
(profile 65WA)

Chapter 8 Custodial Conditions

Summary

8.1 The profiles indicate a growing awareness by custodial and medical staff of issues concerning the proper treatment of both Indigenous and non-Indigenous prisoners. However, implementation of the recommendations is uneven. Some recommendations have not been implemented in any jurisdiction.

8.2 In nine of the 61 investigated cases concerning deaths in institutional settings there was evidence that police, prison officers and medical staff were unaware of their duty of care to detainees. There was also a noted absence of internal disciplinary proceedings to deal with breaches of instructions relating to the care of people in custody. 8.3 De-briefing procedures have not been properly utilised to prevent future deaths in the same circumstances. Avoidable deaths occurred in almost identical circumstances in a number of cases. 8. 4 Deaths of Indigenous people in police cells and vans have decreased since the Royal Commission. However, all of the sixteen investigated deaths in police custody revealed numerous breaches of Royal Commission recommendations. 8.5 The circumstances of deaths in police cells and vans indicated that:

a. There was a lack of proper assessment procedures and little involvement of medical personnel, including Aboriginal Health Services.

b. There was often no protocol for dealing with intoxicated people, particularly in Queensland and Victoria.

c. Police officers were insufficiently trained to distinguish intoxication from other injuries. Persons who needed urgent medical help were frequently detained;

d. The observation of detainees was often irregular and infrequent; and

e. The Aboriginal Visitor Scheme does not appear to fully implemented.

8.6 The increase in the number of deaths in prisons calls for increased scrutiny of the operation and funding of prisons, particularly in relation to health services and general prison conditions.

8.7 The circumstances of deaths in prisons indicated that:

a. Health services in some prisons were well below community standards;

b. The provision of psychiatric services is a continuing problem in all jurisdictions;

c. In one third of the cases 'at risk' information concerning the deceased was not passed between medical and prison staff, or from police to prisons. It is extremely important that this situation is urgently remedied;

d. The rate of suicide in Queensland prisons was twice the national average. In eight of the nine of the investigated deaths there was no protocol for those at risk of self-harm. In other States protocols for self-harm were sometimes unsatisfactory or were not followed by staff;

e. Medical staff and prison officers were often not aware of cross-cultural health issues, particularly heart disease, and performance on the recruitment of Indigenous staff was poor;

f. Some jurisdictions have not fully implemented recommendation 156 through providing an assessment on the reception of prisoners by a medical practitioner. This was a contributing factor in a number of deaths; and

g. There was a lack of proper procedures for the exchange of medical information between external health services and prison staff.

8.8 Some delay or deficiency in attempting to resuscitate detainees was evident in 17 of the 61 cases investigated by the coroners. Problems were caused by inappropriate security procedures which delayed access to prisoners locked in cells, inadequate training and faulty resuscitation equipment. Despite all states and territories claiming implementation of recommendation 161 the failure to seek medical attention when doubts arose as to the medical condition of prisoners was a serious problem in the deaths under investigation.

8.9 Of the four Aboriginal people shot by police between May 1989 and May 1996, three were mentally ill and the fourth was a highly intoxicated 16 year old. None had firearms. Police firearms training was criticised as focussing on the 'criminal element' only, instead of contemplating people with mental disabilities. Guidelines for the use of restraint equipment were also found not to comply with Royal Commission recommendations.

8.10 There are indications that prisoners are still being charged with criminal offences or breaches of prison regulations in relation to suicide attempts.

8.11 Some of the cases provided information on recommendations concerning general prison conditions. Few prisons have employed Aboriginal Welfare Officers and implemented a transitional period to assist remandees or freshly sentenced prisoners in adjusting to prison life. In some prisons shared cell accommodation was not available.

Introduction

Improvement of custodial conditions is critical for all prisoners. Further, prisons are disproportionately comprised of people from disadvantaged backgrounds including those from different cultural and racial backgrounds and people with mental illness.

Significant progress has been made in improving custodial conditions since the Royal Commission found, 'glaring deficiencies in the standard of care afforded many of the deceased during... the period of incarceration.' Coronial inquests indicate an improvement in screening procedures, provision of physical and mental health services, training of police and prison officers and better cell conditions. However, implementation is still partial and varies significantly across Australia. The above statement of the Western Australian Police Union Secretary indicates the cultural and attitudinal changes have a significant way to go.

Recommendations concerning custodial conditions have been broken down into six sections. Section 1 concerns duty of care, disciplinary action and de-briefing procedures for police and prisons (R122-4). Section 2 addresses custodial health and safety of detainees in police custody (R125-49) while section 3 concerns custodial health and safety in prisons. Section 4 considers general custodial health and safety issues relevant to both police and prisons. Section 5 addresses recommendations concerning prisoner welfare (R168-87). Section 6 considers medical care outside prison and police cells as hospitals and non-prison doctors there were involved in the medical care of a number of the deceased. Recommendation 167 concerning juveniles is addressed in chapter 9.

The increase in the number of deaths in prison and the decline of deaths in police cells raises questions as to the interpretation of the recommendations. The Royal Commission provided more detailed recommendations on health and safety in police custody (R125-4). These recommendations should be used by Prison Medical Services in interpreting the briefer recommendations concerning prisons, ² particularly given the speedier transfer of detainees, as discussed in chapter 2. ³ However, for the purposes of this Report these recommendations will only be considered in deaths occurring in police custody.

1. Duty of Care, Discipline and De-briefing Procedure

Table 8.1 Duty of Care, Discipline and De-briefing Procedure

View the table

Recommendation 122 - Recognition of the Duty of Care
That Governments ensure that:

1. Police Services, Corrective Services, and authorities in charge of juvenile centres recognize that they owe a legal duty of care to persons in their custody;
2. That the standing instructions to the officers of these authorities specify that each officer involved in the arrest, incarceration or supervision of a person in custody has a legal duty of care to that person, and may be held legally responsible for the death or injury of the person caused or contributed to by a breach of that duty; and
3. That these authorities ensure that such officers are aware of their responsibilities and trained appropriately to meet them, both on recruitment and during their service.

In at least ten cases it was clear that police and prison officers were unaware of their duty of care or the relevant instructions (27NSW, 39NSW, 62NSW, 67NSW, 14QLD, 21QLD, 25QLD, 53QLD, 1SA and 65WA).

New South Wales, Victoria, Western Australia and Northern Territory claimed implementation of this recommendation. The remaining jurisdictions claimed part implementation.

Six of the cases occurred in police cells. In all of the cases police officers were not aware of their instructions and in five of the cases coroners also recommended that instructions be revised. The cases demonstrate that recommendation 122c cannot be adequately implemented without an increase in the length and quality of police training.

In the death at Mornington Island Watch-house (21QLD) the Coroner held that there was a failure on the part of all individuals on duty during the incarceration of the deceased at the police watch-house to properly perform their custodial duty and responsibility. He found that the practice of driving past the watch-house and observing the cells by shining the headlights through the front screen mesh was improper and inadequate and not in accordance with General Instructions, and inspections of prisoners were infrequent and not in accordance with instructions. The Coroner also recommended that the General Instructions be revised to be consistent with Royal Commission recommendations.

In the death of a 34 year old man at Rockhampton Watch-house (25QLD) the Coroner found that in training police officers were simply shown a list of orders on a wall upon commencement at the police station. The Coroner found that the police officers were young and inexperienced and unaware of proper procedures. He recommended that the standing orders at Rockhampton Watch-house be totally revised and urgently updated and include the recommendations of the Royal Commission.

A similar finding was made in the case of the woman who died at Macquarie Fields Police Station (39NSW). The Coroner found that the police officers were young and inexperienced and unaware of the proper procedures for looking after detainees. The assessment form was incorrectly filled out and records of observation were not kept. The Coroner also found that Police Instructions were regularly breached in keeping sentenced prisoners in police cells.

In the death of a man in a police van in Brisbane (53NSW) the Coroner found that two police officers did not have sufficient, if any, knowledge of the contents of the Custody Manual. He also found that there was an inadequate system in place to ensure that all officers complied with the circulars and familiarised themselves with the contents of the Custody Manual.

In the case of the man who died at Ceduna Police Station (1SA) the Coroner recommended that there be centrally located circulars and guidelines which all staff be required to read. In this case the deceased was not regularly observed and observations were not recorded.

In the case of the man who died at East Perth Lockup, police failed to comply with a number of procedures in their assessment and observation of the deceased. The response of the Secretary of the Western Australian Police Union, that police don't have a responsibility to look after 'crooks,' is an indicator of the attitudinal change still required by recommendation 122.

Four other cases involved prisons. In the case of the 33 year old man who died at Long Bay Prison (27NSW), the Coroner found that Long Bay Prison had not implemented his earlier recommendations concerning exchange of information between prison and medical officers. There was a series of mis-communications between prison and medical offices that eventually contributed to the man's death. The 30 year old woman who died in Mulawa Prison was not given medical attention despite evidence that she lay in her cell all night, moaning audibly. In the death of a 19 year old man at Parklea Prison (67NSW) the Coroner questioned whether the Prison Health Service comprehended their duty of care, after medical staff failed to communicate 'at risk' information to prison officers. As discussion under recommendation 152f indicates, there was a failure in many cases to communicate information between prison and medical staff. In the death of a 21 year old man at Rockhampton Prison on 2 April 1990 (14QLD) the Coroner found that prison officers did not understand procedures for dealing with inmates at risk and that these procedures were in need of development.

Courts in New South Wales have recently awarded damages to relatives of Aboriginal people who have died in custody on the basis that custodial officers and hospital staff breached their duty of care.⁴ It will be unfortunate if this is the method by which police and prison services comprehend their duty of care and subsequent responsibilities.

Recommendation 123 - Personal Accountability for Breaches of Instructions
That Police and Corrective Services establish clear policies in relation to breaches of departmental instructions. Instructions relating to the care of persons in custody should be in mandatory terms and  be both enforceable and enforced. Procedures should be put in place to ensure that such instructions are brought to the attention of and are understood by all officers and that those officers are made aware that the instructions will be enforced. Such instructions should be available to the public.

The existence of disciplinary procedures for breaches of instructions was not apparent in any of the ten cases discussed under recommendation 122. All jurisdictions claimed implementation except Tasmania who claimed part implementation.

In one of these cases (62NSW) the employees who were found to be extremely negligent by the coroner received counselling. In another case (67NSW), the Minister of Corrective Services held an investigation into the circumstances of the death, after a recommendation from the Coroner. The Board of Inquiry established by the Minister found that certain medical staff had breached guidelines but that the trauma of the experience and interview with the Board was sufficient discipline.

Recommendation 124 - De-briefing Following Incidents
That Police and Corrective Services should establish procedures for the conduct of de-briefing sessions following incidents of importance such as deaths, medical emergencies or actual or attempted suicides so that the operation of procedures, the actions of those involved and the application of instructions to specific situations can be discussed and assessed with a view to reducing risks in the future.

All jurisdictions claimed implementation except Tasmania which claimed part implementation. Coroners commented upon the deficiencies of de-briefing procedures in two cases. The Coroner in the death of a 19 year old man at Parklea Prison (67NSW) found that the debriefing procedure was inadequate and sessions were poorly attended by staff. Debriefing procedures were also inadequate following the death of a woman in Mulawa Prison in 1994 (62NSW). The Coroner in the death of a 24 year old man at Rockhampton Prison (14QLD) found that no procedures were put in place after the deaths to accompany an 'at risk' classification despite the self-induced death of two inmates at the Prison. The occurrence of indistinguishable deaths at certain institutions such as Townsville Watch-house, Rockhampton Watch-house, Yatala Prison and the police car chase deaths in Western Australia, raise questions as to the effective use of de-briefing procedures, systems of communication and information exchange.

De-briefing procedures should also be structured appropriately. In the case of the man who died in a Brisbane Police Van (53QLD), Commissioner Wyvil recommended that officers should provide independent statements of events before the debriefing procedure to avoid recollection being affected by the views of other officers.

2. Custodial Health and Safety: Police

There were 35 deaths in police custody from June 1989 to May 1996. Seventeen of these cases involved police pursuit. These deaths only raise issues of arrest and Aboriginal-police relations which are discussed in chapter 6. The remaining 18 cases involved deaths in police vans (4) and watch-houses (14). ⁵

In the latter cases the person sometimes died in hospital. In two of the cases the inquest had not commenced at the time of writing this Report, and consequently, coronial findings and legal submissions were unavailable.⁶

Almost all the cases involved people under the influence of alcohol or people whom the police presumed were under such an influence. ⁷ It is not surprising that the deaths were therefore concentrated in Queensland and Victoria where drunkenness has not been decriminalised. However, only two of the deaths were the direct result of drugs or alcohol. Six of the deaths were self-inflicted, seven from natural causes, and three from injuries.

Many of the cases could have been prevented if non-discretionary procedures recommended by the Royal Commission were put in place. As Table 8.2 shows, recommendations concerning assessment (R125, 126), regular nursing presence (R127a), protocols for intoxicated people (R127f(i)) and regular and careful checks on detainees (R137) were frequently breached. The most frequently breached recommendation was recommendation 133 which required training for police to identify those in distress as well as training to recognise the dangers and misconceptions associated with alcohol.

The decrease in deaths in police vans and cells, as noted in chapter 2, is welcome. This can be seen in Table 8.2 where breaches are concentrated in the first period. The decline in deaths in police cells may be, to a degree, a result of implementation of recommendations. It is also likely to be a result of speedier transfer of detainees to remand centres. As chapter 2 revealed, deaths that may have occurred in police cells now occur in prison, particularly self-inflicted deaths which occur in the early stages of detention.

Governments claimed full implementation of almost all recommendations concerning health and safety in police custody (see Part C Appendix). Tasmania does not support 140, 144, 145, 146 and 149.

Table 8.2 Custodial Health and Safety: Police

View the table

Recommendation 125 - Introduction of a Screening Form
That in all jurisdictions a screening form be introduced as a routine element in the reception of persons into police custody. The effectiveness of such forms and procedures adopted with respect to the completion of such should be evaluated in the light of the experience of the use of such forms in other jurisdictions.

Coronial summaries do not always reveal whether a screening assessment was carried out. Two of the early Queensland cases clearly indicate that no assessment occurred (3QLD, 5QLD).

In three other Queensland cases (21QLD; 25QLD; and 32 QLD) the completion of a comprehensive screening form would have revealed the need of the deceased for medical attention. Two of the deceased had serious head injuries and one had epilepsy. The death at East Perth Lockup (65WA) raised similar problems. The deceased stated to the police at reception that he was on medication for blood pressure, had chest pains, was a regular drinker, had been recently hospitalised and that he had a headache. However, his health was assessed by police as 'OK'.

The case of the death at Parklea Prison (67NSW) illustrated an effective police assessment form. Certain answers from interviewees lead to non-discretionary responsive action by police. In that case a prior suicide attempt automatically tagged the deceased as a high suicide risk. This approach compensates for the lack of police experience in detecting physical and mental health problems. Police forms should also have questions on symptoms, particularly for heart disease, as was recommended by Deputy Coroner Abernathy in the death at Broken Hill Prison (71NSW).

Recommendation 126 - Thorough Assessment of Screening Forms
That in every case of a person being taken into custody, and immediately before that person is placed in a cell, a screening form should be completed and a risk assessment made by a police officer or such other person, not being a police officer, who is trained and designated as the person responsible for the completion of such forms and assessment of prisoners. The assessment of a detainee and other procedures relating to the completion of the screening form should be completed with care and thoroughness.

In five cases the screening form was not completed thoroughly.⁸ In the death at Macquarie Fields Police Stations (39NSW) the form was filled out incorrectly and the police did not inquire of the deceased's Aboriginality. In the death at Bendigo Police Station, police did not believe the deceased when he said he was Aboriginal (31VIC). In the case at Gippsland Hospital (8VIC) only a perfunctory check was made by the police surgeon. In the two other cases police failed to pick up information as to the mental (1SA) and physical (2WA) health status of the deceased.

Recommendation 127 - Appropriate Health Care
That Police Services should move immediately in negotiation with Aboriginal Health Services and government health and medical agencies to examine the delivery of medical services to persons in police custody. Such examination should include, but not be limited to, the following:

1. The introduction of a regular medical or nursing presence in all principal watch-houses in capital cities and in such other major centres as have substantial numbers detained;
2. In other locations, the establishment of arrangements to have medical practitioners or trained nurses easily available to attend police watch-houses for the purpose of identifying those prisoners who are at risk through illness, injury or self-harm at the time of reception;
3. The involvement of Aboriginal Health Services in the provision of health and medical advice, assistance and care with respect to Aboriginal detainees and the funding arrangements necessary for them to facilitate their greater involvement;
4. The establishment of locally based protocols between police, medical and para-medical agencies to facilitate the provision of medical assistance to all persons in police custody where the need arises;
5. The establishment of proper systems of liaison between Aboriginal Health Services and police so as to ensure the transfer of information relevant to the health, medical needs and risk status of Aboriginal persons taken into police custody; and

6. The development of protocols for the care and management of Aboriginal prisoners at risk, with attention to be given to the specific action to be taken by officers with respect to the management of: 

   i. intoxicated persons;
   ii. persons who are known to suffer from illnesses such as epilepsy, diabetes or heart disease or other serious medical conditions;
   iii. persons who make any attempt to harm themselves or who exhibit a tendency to violent, irrational or potentially self-injurious behaviour;
   iv. persons with an impaired state of consciousness;
   v. angry, aggressive or other wise disturbed persons;
   vi. persons suffering from mental illness;
   vii. other serious medical conditions;
   viii. persons in possession of, or requiring access to, medication; and
   ix. such other persons or such situations as agreed.

In seven cases it was evident that there was no regular medical nursing presence in the watch-houses in accordance with recommendation 127a. (39NSW, 5QLD 21QLD 25QLD 38QLD, 65WA). The presence of nursing and medical staff is critical to compensate for police inexperience in detecting medical conditions in accordance with recommendations 125, 126, 133. Likewise a number of cases clearly indicated the non-involvement of Aboriginal Health Services (8VIC, 1SA, 65WA). Furthermore, in none of the case was there an attempt to secure medical files or information from other sources.

There was also a lack of protocols under recommendation 127f. There were no protocols for dealing with intoxicated people under recommendation 127f in a large number of cases (3QLD, 5QLD, 21QLD, 25QLD, 38QLD, 53QLD, 8VIC, 31VIC, 38VIC). In A number of other cases it was clear that there was no protocols for:

• heart disease (65WA) - recommendation 127f(ii);
• self-harm (39NSW) - recommendation 127f(iii); and
• medication (65WA) - recommendation 127f(viii)

Recommendation 128 - Care for Corrective Services Prisoners in Police Lockups
That where persons are held in police watch-houses on behalf of a Corrective Services authority, that authority arrange, in consultation with Police Services, for medical services (and as far as possible other services) to be provided not less adequate than those that are provided in correctional institutions.

Two case concerned prisoners held in police watch-houses on behalf of Corrective Services: the woman who died at Macquarie Fields (39NSW) and the woman who died at Mulawa prison (62NSW). In the former case the Coroner in that case criticised the arrangement whereby sentenced prisoners were held in police cells in breach of the court warrant, the Prison Act and the Police Commissioner's instructions. He also expressed concern at the standard of care at the Police Station. In the latter case the deceased was in medical distress, and was on record as suffering a serious heart condition, but was not given medical attention on either of the two occasions that she was held in police custody on behalf of Corrective Services in the days prior to her death. A form indicated that the deceased was sick and had endocarditis.

Recommendation 129 - Breath Analysis Equipment to Confirm Drunkenness
That the use of breath analysis equipment to test the blood alcohol levels at time of reception of  persons be thoroughly evaluated by Police Services in consultation with Aboriginal Legal Services, Aboriginal Health Services, health departments and relevant agencies.

There were two cases in Queensland and Victoria in which people who died in custody after being charged with public drunkenness were found not to be intoxicated (38QLD, 8VIC). These cases indicate that this recommendation has merit, although no jurisdiction has implemented it.

Recommendation 130 - Transfer of Medical Information
That:

1. Protocols be established for the transfer between Police and Corrective Services of information about the physical or mental condition of an Aboriginal person which may create or increase the risks of death or injury to that person when in custody;
2. In developing such protocols, Police Services, Corrective Services and health authorities with Aboriginal Legal Services and Aboriginal Health Services should establish procedures for the transfer of such information and establish necessary safe-guards to protect the rights of privacy and  confidentiality of individual prisoners to the extent compatible with adequate care; and
3. Such protocols should be subject to relevant ministerial approval.

A number of New South Wales cases revealed that relevant health information was not successfully transferred between police and prisons. In the case of the man who died at Westmead Hospital (7NSW), the mother of the deceased had told a police officer of the deceased's ear problems but this information was not passed onto the prion. In the case of the 19 year old man who died at Parklea Prison (67NSW), the Board of Inquiry (Response of Minister to the Coroner) found that police assessment forms were generally not available or not used in the assessment of remand or freshly sentenced prisoners at Parklea Prison. The need for improvement in prison reception procedures is discussed in recommendation 157. For discussion of confidentiality issues see recommendation 152e and 153b.

Recommendation 131 - Police Officers to Record Observations of Prisoners
That where police officers in charge of prisoners acquire information relating to the medical condition of a prisoner, either because they observe that condition or because the information is voluntarily  disclosed to them, such information should be recorded where it may be accessed by any other police officer charged with the supervision of the prisoner. Such information should be added to the screening form referred to in Recommendation 126 or filed in association with it.

In the cases at Rockhampton Police Watch-house (25QLD) and East Perth Lockup (65WA) the deceased were vomiting during the night before they died. This was not noted by police. Both of the detainees died of natural causes.

Recommendation 132 - Passing of Information to Incoming Shift
That:

1. Police instructions should require that the officer in charge of an outgoing shift draw to the attention  of the officer in charge of the incoming shift any information relating to the well being of any prisoner  or detainee and, in particular, any medical attention required by any prisoner or detainee;
2. A written check list should be devised setting out those matters which should be addressed, both in writing and orally, at the time of any such handover of shift; and
3. Police Services should assess the need for an appropriate form or process of record keeping to be devised to ensure adequate and appropriate notation of such matters.

In the case at East Perth Lockup (65WA) there was no exchange of information between the Officers in Charge as to the health of the deceased. The Officer in Charge was completely unaware as to relevant information concerning the deceased. The issue did not arise in other cases as relevant information in the screening process was not obtained or there was no change of shifts. This recommendation is also important in relation to prisons, as illustrated by the death of the young man at Parklea Prison (67NSW).

Recommendation 133 - Basic Training to Identify Conditions
That:

1. All police officers should receive training at both recruit and in-service levels to enable them to identify persons in distress or at risk of death or injury through illness, injury or self-harm;
2. Such training should include information as to the general health status of the Aboriginal population,  the dangers and misconceptions associated with detaining unconscious or semi-rousable persons and  the specific action to be taken by officers in relation to those matters which are to be the subject of  protocols referred to in recommendation 127;
3. In designing and delivering such training programs, custodial authorities should seek the advice and assistance of Aboriginal Health Services and Aboriginal Legal services; and
4. Where a police officer or other person is designated or recognized by a police service as being a person whose work is dedicated wholly or substantially to cell guard duties then such person should receive a more intensive and specialised training than would be appropriate for other officers.

This recommendation was made in the Interim Report (R14) and was the most frequently breached recommendation. The cases clearly revealed that police were generally unable to identify detainees at risk. This indicates the need for more intensive police training beyond the cursory one or two day courses at police academies. Both 'on the job' training and recruit training in custody procedures needs to be improved in all jurisdictions. The training programs should be designed in conjunction with experts in the field of custodial procedures and Aboriginal Organisations with an interest in custodial issues. The recommendation also recognises the critical need for non-discretionary procedures such as screening assessments, checking of detainees and a nursing and medical presence.

In four of the cases the deceased were arrested for drunkenness when they were suffering from illnesses and injury (21QLD, 25QLD, 38QLD, 8VIC). Police assumed from previous charges for drunkenness, or the deceased's behaviour, that they were intoxicated. Two of the cases involved persons with epilepsy and two cases of head injuries. The need for police to distinguish between intoxication and illness is clearly set out in recommendation 133b and Interim Report recommendation 14.

The use of sobering-up facilities is relevant to this recommendation. Sobering up facilities are a welcome alternative from police cells. However, police need training to ensure that people suffering from other illnesses are not inappropriately conveyed to such facilities. A permanent nursing presence is also needed at sobering-up facilities. The death at a sobering up centre in South Australia (A1SA) is illustrative. The police assumed the deceased was drunk and drove him to a centre when the deceased was actually suffering from a fractured skull.

In four other cases the deceased were placed in the back of police vans for long periods of time (42NSW, 50NT, 53QLD, 36VIC). The case in the Northern Territory was not listed as a breach of this recommendation as the inquest has not yet commenced. In all cases the deceased were under the influence of drugs and in three of the cases exhibited symptoms of other illnesses. The placement of the detainees unobserved and handcuffed in police vans for significant periods of time is extremely dangerous. The officer in charge of the safety in custody taskforce in New South Wales is not of senior rank, indicating that this area is not a priority for the Service.

In cases involving self-inflicted hanging none of the deceased was recognised as a suicide risk (39NSW, 96NT, 3QLD, 1SA, 31VIC). In two of the cases there were signs of suicidal intent. In the case at the Ceduna Police Station (1SA) the deceased was angry and frustrated at arrangements concerning transport to court after being denied bail. In the case of the man who died at Bendigo Police Station (31VIC) the police disbelieved the deceased's statement that he was Aboriginal, did not allow for withdrawal from alcohol and consider the deceased's anxiety about returning home to his wife after losing a sum of money (31VIC). Recognition of the risk of self-harm is difficult. However, police should be aware of the propensity of detainees to commit suicide within the early stage of detention. They should therefore be acutely vigilant and on the look-out for signs of self-harm.

Other cases involved natural causes and injuries. In the death at Rockhampton Watch-house (5QLD) the deceased was unconscious and black ants were crawling over his clothes and hair (5QLD). Instead of being taken to a hospital he was arrested for public drunkenness. In the death at Palm Island Watch-house (32QLD) the deceased had serious head injuries but was arrested for public drunkenness and taken to police cells. In the East Perth Lockup case (65WA) the deceased responded positively to questions about chest pain and medication yet no action was taken. He later died of heart disease contributed to by alcohol withdrawal. In the case at Port Headland Lockup the deceased died of a heart attack after being arrested for drunkenness (2WA). From the short coronial summary it is unclear whether he exhibited signs of heart disease or whether he was in fact intoxicated.

Recommendation 134 - Humane Treatment of Detainees

That police instructions should require that, at all times, police should interact with detainees in a  manner which is both humane and courteous. Police authorities should regard it as a serious breach of discipline for an officer to speak to a detainee in a deliberately hurtful or provocative manner.

The cases in Brisbane Police custody (53QLD) and Gippsland Sale Hospital (8VIC) raise questions as to humane treatment. In the first case the deceased was handcuffed and placed face down in a police vehicle. The police van was then driven around the area looking for more of the group while the deceased suffered a heart attack. In the second case the deceased was semi-rousable yet handcuffed and held in police cells for 10 hours.

Recommendation 135 - Transport semi-rousable persons to hospital
In no case should a person be transported by police to a watch-house when that person is either unconscious or not easily roused. Such persons must be immediately taken to a hospital or medical practitioner or, if, neither is available, to a nurse or other person qualified to assess their health.

This recommendation was earlier made in the Interim Report and recommended by a Coroner in the second post-Royal Commission death in Queensland (5QLD). However, this recommendation was breached in six cases. In two of the cases the deceased was unconscious (5QLD, 21QLD) while in four cases the deceased was semi-rousable due to injuries and illness (32QLD, 38QLD, 53QLD and 36VIC). In all cases it was assumed that the deceased were simply intoxicated.

Recommendation 136 - Transport semi-rousable persons in cell to hospital
That a person found to be unconscious or not easily rousable whilst in a watch-house or cell must be immediately conveyed to a hospital, medical practitioner or nurse. (Where quicker medical aid can be summoned to the watch-house or cell or there are reasons for believing that movement may be dangerous for the health of the detainee, such medical attendance should be sought).

Four of the persons mentioned in recommendation 135 were taken back to watch-houses and cells (5QLD, 21QLD, 32QLD and 38QLD) and not subsequently taken to a hospital. In another case the deceased, who was semi-rousable, was actually taken from a hospital by police (8VIC).

Recommendation 137 - Observation
That:

1. Police instructions and training should require that regular, careful and thorough checks of all detainees in police custody be made;
2. During the first two hours of detention, a detainee should be checked at intervals of not greater than fifteen minutes and that thereafter checks should be conducted at intervals of no greater than one hour;
3. Notwithstanding the provision of electronic surveillance equipment, the monitoring of such persons in the periods described above should at all times be made in person. Where a detainee is awake, the check should involve conversation with that person. Where the person is sleeping the officer should ensure that the person is breathing comfortably and is in a safe posture and otherwise appears not to  be at risk. Where there is any reason for the inspecting officer to be concerned about the physical or mental condition of a detainee, that person should be woken and checked; and
4. Where any detainee has been identified as, or is suspected to be, a prisoner at risk then the prisoner or detainee should be subject to checking which is closer and more frequent than the standard.

This recommendation was the most frequently breached recommendation after 133. Coroners have stated that the regularity and type of checks on detainees must depend on the circumstances (see profile 4NSW for example).

Four of the cases involved deaths in police vans (42NSW, 50NT, 53QLD and 38VIC). ⁹ As arrestees are obscured from view in police vans, constant checks need to be maintained. This is particularly so if the arrest involved force and the deceased is handcuffed, as happened in three of the cases. Police will often have little knowledge of the person's health and vigilance is therefore necessary. In the death of an 18 year old man in Brisbane on 13 November 1993 (53QLD), Commissioner Wyvil recommended that consideration be given to the establishment of a means of communication between the occupants of special purpose vehicles of the type involved in this case and those persons imprisoned in the secure area of those vehicles.

In four other cases coroners criticised the frequency of checks (39NSW, 3QLD, 21QLD and 1SA). In the first Queensland case surveillance equipment had not been installed in the Police Watch-house as previously recommended by the Coroner, while in 21QD the police left police aides in charge, and made infrequent checks on detainees from the car park or as they drove past.

In three other cases it was clear that checks were not sufficient. In the death at Sale Police Station (8VIC) the deceased was not checked every 15 minutes for the first two hours, as required. The man had been wrongly arrested for drunkenness in a public hospital while semi-conscious after suffering an epileptic fit. In the death of a 34 year old man at Rockhampton Watch-house, the Coroner found that the deceased had been checked regularly during the night by police looking through the cell door. However, the findings are not convincing. Rigor mortis had set in by the morning.

That he had not arisen out of bed in almost 24 hours casts doubt on statements that appropriate checks took place. If checks took place they were clearly not diligent and adequate for a person in the condition of the deceased. There was no reference in the findings to written records of the checks. In the case of the death of a man in the Port Headland Lockup (2WA) in 1989 the Coroner found that hourly checks were made. The deceased had been found staggering on a road and was arrested. The Royal Commission's interim report released eight months earlier had emphasised the need for more regular checks of intoxicated persons.

Recommendation 138 - Recording of Information
That police instructions should require the adequate recording, in relevant journals, of observations and information regarding complaints, requests or behaviour relating to mental or physical health, medical attention offered and/or provided to detainees and any other matters relating to the well being of detainees. Instructions should also require the recording of all cell checks conducted.

In seven cases observations were not recorded (39NSW, 21QLD, 25QLD, 38QLD, 8VIC, 31VIC and 65WA). As noted under recommendation 131, changes in medical condition were not noted in two cases (21QLD, 65WA).

Recommendation 139 -TV Monitoring
The Commission noted recent moves by Police services to install TV monitoring devices in police cells. The Commission recommends that:

1. The emphasis in any consideration of proper systems for surveillance of those in custody should be on human interaction rather than on high technology. The psychological impact on the use of such equipment on a detainee must be borne in mind, as should its impact on that person's privacy. It is preferable that police cells be designed to maximise direct visual surveillance. Where such equipment has been installed it should be used only as a monitoring aid and not as a substitute for human interaction between the detainee and his/her custodians; and
2. Police instructions specifically direct that, even where electronic monitoring camera are installed in police cells, personal checks be maintained.

The issue of electronic monitoring was raised in two cases. In profile 3QLD the coroner recommended video surveillance equipment, but did not address the issue of cameras being used with proper human interaction and checks of detainees. In profile 31VIC, where the deceased was found hanging in a shower recess hidden to surveillance cameras, the detainee had been physically checked 35 minutes earlier. The coroners generally did not comment on the level of human interaction in cases where electronic monitoring was used.

Recommendation 140 - Alarm System
That as soon as practicable, all cells should be equipped with an alarm or intercom system which gives direct communication to custodians. This should be pursued as a matter of urgency at those police watch-houses where surveillance resources are limited.

In the death at Macquarie Fields Police Station (39NSW) where the Coroner recommended installation of computer operated alarm buttons in police cells. In two prison deaths there was no alarm system in the cells (6NSW and 85WA).

Recommendation 141 - Supervision
That no person should be detained in a police cell unless a police officer is in attendance at the watch-house and is able to perform duties of care and supervision of the detainee. Where a person is detained in a police cell and a police officer is not so available then the watch-house should be attended by a person capable of providing care and supervision of persons detained.

In the Mornington Island Watch-house case (21QLD), Aboriginal community police aides were left to supervise the deceased in breach of instructions and police only checked as they drove past the watch-house. The recent death on Tiwi Island indicates the problem of this recommendation for remote areas and communities (96NT). Procedures should be put in place so that other people, eg community wardens, can supervise detainees if police officers are elsewhere.

Recommendation 142 - Padded Cells
That the installation and/or use of padded cells in police watch-houses for punitive purposes or for the management of those at risk should be discontinued immediately.

There was no information presented by the case profiles.

Recommendation 143 - Proper Meal at Regular Times
All persons taken into custody, including those persons detained for intoxication, should be provided with a proper meal at regular meal times. The practice operating in some jurisdictions of excluding persons detained for intoxication from being provided with meals should be reviewed as a matter of priority.

Most of the cases revealed that meals were provided to the deceased. However, in the death of a woman at Mulawa (62NSW) sandwiches were found in the deceased's cell, and, although it was apparent that she was very ill, no-one had attempted to ensure that she could eat them or receive more appropriate nourishment.

Recommendation 144 - Shared cells
That in all cases, unless there are substantial grounds for believing that the well being of the detainee or other persons would be prejudiced, an Aboriginal detainee should not be placed alone in a police cell. Wherever possible, an Aboriginal detainee should be accommodated with another Aboriginal person. The views of the Aboriginal detainees and such other detainee should be sought. Where placement in a cell alone is the only alternative the detainee should thereafter be treated as a person who requires careful surveillance.

Quality of surveillance or monitoring is dependent on individual psychological assessment following the physical isolation of a detainee. A number of profiles in this report outline instances where inadequate supervision and monitoring of detainees apparently alone in police cells has contributed to deaths. See, for example 39NSW, 25QLD, 32QLD, 38 QLD, 8VIC, 31VIC. These examples count for few of the deaths in custody in the period of reporting, although they are a significant ratio of the group who died in police custody. It is noted that increasingly the general practice of most police lockups is to 'encourage Aboriginal prisoners to share cells with each other'.' ¹⁰ Tasmania does not support this recommendation.

Recommendation 145 - Aboriginal Visitor Scheme
That:

1. In consultations with Aboriginal communities and their organizations, cell visitor schemes (or schemes serving similar purposes) should be introduced to service police watch-houses wherever practicable;
2. Where such cell visitor schemes do not presently exist and where there is a need or an expressed interest by Aboriginal persons in the creation of such a scheme, government should undertake negotiations with local Aboriginal groups and organization towards the establishment of such a scheme. The involvement of the Aboriginal community should be sought in the management and operation of the schemes. Adequate training should be provided to persons participating in such schemes. Governments should ensure that cell visitor schemes receive appropriate funding.
3. Where police cell visitor schemes are established it should be made clear to police officers performing duties as custodians of those detained in police cells that the operation of the cell visitor schemes does not lessen, to any degree, the duty of care owed by them to detainees; and
4. Aboriginal participants in cell visitor schemes should be those nominated or approved by appropriate Aboriginal communities and/organizations as well as by any other person whose approval is required by local practice.

The cases indicate that proper heed is not being paid to input into prisoner welfare potentially provided by the Aboriginal Visitor schemes.

The man who died in Bendigo police station in Victoria told police that he was Aboriginal, but they did not believe him (31QLD). As a result the Community Justice Panel was not informed when the deceased was taken into custody.

In the case of the woman who died following her arrest for drunkenness in Brisbane (38QLD) the police did not follow agreed protocols which set out the details to be given to Murri Watch, an Aboriginal organisation which diverts intoxicated persons from police custody. Murri Watch was contacted, and apparently told the deceased had soiled herself. The woman was incorrectly described as being intoxicated - in fact she had suffered a heart attack. The representative responded that he would let her sleep it off and pick her up in a few hours.

Watch-house procedures for recording notification of Murri Watch, and recording their response, were not complied with. The investigator specified that details should have included her inability to answer questions about her health; the lack of a detectable odour of alcohol; her impaired consciousness; her inability to stand, requiring her to be carried; the fact that she was not violent or aggressive; the arrangements made to clean up faeces; and the lack of any medical examination.

In the case of the man who died in Townsville Prison in 1994 (64QLD), the Police and Corrective Services Minister denied that prison authorities had been informed by the Gurrindal Cell Visitors Program that the deceased had made suicide threats while at the Townsville Watch-house prior to being taken to the Remand Centre. ¹¹ An Indigenous woman appointed to the investigation team made a formal complaint about the refusal to grant her access to information which tended to corroborate that claim, including a form indicating that the deceased was 'at risk' of self-harm.

The case of the man who died at the East Perth Lockup in 1994 (65QLD) visitors from the Aboriginal Visitor Scheme noted in the Visitors Book at the Police Station that the deceased's medication was at the night shelter. Police did not become aware of this information until after the death, as there was no procedure for examining the Visitors Book.

Recommendation 146 - Visits from Family and Friends
That police should take all reasonable steps to both encourage and facilitate the visits by family and friends of persons detained in police custody.

In the case of the man who died in Arthur Gorrie Remand Centre in 1993 (45QLD) the Coroner strongly criticised the denial of a request for a visit by the immediate family. The death raises the issue of police recommendations extending to remand facilities.

The deceased had been moved from the Brisbane Watch-house on the day of his arrest, on the basis that he was a suicide risk. The Remand Centre rules allowed only week-end visits. Prisoners are extremely vulnerable to self harm and suicide in the initial stages of their incarceration, with the proportion of deaths among remand prisoners being three and a half times greater than in the general prison population.¹²

Recommendation 147 - 'At Risk' Notification to Families
That police instructions should be amended to make it mandatory for police to immediately notify the relatives of a detainee who is regarded as being 'at risk', or who has been transferred to hospital.

Unfortunately, there was little information on this recommendation. However, in the case of the man who died in Arthur Gorrie Remand Centre in Queensland (45QLD) the Coroner was critical of the denial of a request by the immediate family to visit the deceased, who had been moved from the Brisbane Watch-house on the day of his arrest on the basis that he was a suicide risk. There was no indication that the family was informed of this. Their request to visit was flatly refused. This is a crucial recommendation, and coroners must begin to address it.

Recommendation 148 - Safe cells
That whilst there can be little doubt that some police cell accommodation is entirely substandard and must be improved over time, expenditure on positive initiatives to reduce the number of Aboriginal people in custody discussed elsewhere in this report constitutes a more pressing priority as far as resources are concerned. Where cells of a higher standard are available at no great distance, these may be able to be used. More immediate attention must be given to programs diverting people form custody, to the provision of alternative accommodation to police cells for intoxicated persons, to bail procedures and to proceeding by way of summons or caution rather than by way of arrest. All these initiatives will reduce the numbers for whom cell accommodation is required. Where, however, it is determined that new cell accommodation must be provided in areas of high Aboriginal population, the views of the local community and organizations should be taken into account in the design of such accommodation. The design or re-design of any police cell should emphasize and facilitate personal interaction between custodial officers and detainees and between detainees and visitors.

In the case of the death of the 19 year old in the Ceduna police cells (1SA), the ALRM noted that conditions in the cells were poor: it was the middle of winter, the cells were spartan, cold and lacking in adequate exercise space. New cells were in construction by the time the Coroner made his findings.

The Royal Commission noted the poor conditions in the East Perth Lockup in the course of an inquiry into a death there in 1986. ¹³ The ALS of Western Australia indicated that conditions at the cells had not improved by the time another Aboriginal man died in the cells in late 1994 (65WA).

The Rockhampton Watch-house, the site of a death in 1991 (25QLD), was a dilapidated facility. The Coroner did not address this issue. It is now being upgraded, but there has been controversy over the building of underground cells. The Human Rights Commissioner has indicated that access to courtyards is essential if the facility is to comply with the relevant international covenants. ¹⁴ The staffing of the watch-house by inexperienced officers was severely criticised by the Coroner investigating the death.

Recommendation 149 - Flexible Police Custody Arrangements
That Police Services should recognise, by appropriate instructions, the need to permit flexible custody arrangements which enable police to grant greater physical freedoms and practical liberties to  Aboriginal detainees. The Commission recommends that the instructions acknowledge the fact that in appropriate circumstances it is consistent with the interest of the public and also the well being of detainees to  permit some freedom of movement within or outside the confines of watch-houses.

Submissions from the ALRM at the inquest into the death of a 19 year old at the Ceduna Police Station, indicated that flexible custody arrangements recommended by the Royal Commission had been discontinued (1SA). Case profiles also indicated that inappropriate restrictions are being placed on access to exercise yards (1SA, 2WA).

In the case of the death of a woman at Macquarie Fields Police Station (39NSW) there was no exercise yard, although the Coroner noted that two yards were planned for the station.

3. Custodial Health and Safety: Prison

Sixty Aboriginal deaths occurred in prison custody. Of these deaths, 43 have been investigated by coroners. In two other deaths there is sufficient information available to be examined for implementation of recommendations. As noted earlier, the detail of Royal Commission recommendations regarding police custody is useful in interpreting recommendations concerning health and safety in prisons.

The case studies indicate a wide variance in the standard of care as well as idiosyncratic problems at state, territory and individual prison level.

Table 8.3 lists the frequency of breaches. The most frequently breached recommendation was 152f which concerns exchange of information between medical and prison staff. Other frequently breached recommendations include protocols for prisoners at risk of self-harm (R152g(iv)), cross-cultural training for medical staff (152a) and prison staff (155) and the securing of medical information about prisoners (R157). Victoria and Northern Territory claim implementation of the majority of the eight recommendations while the other jurisdictions only claim part implementation (see Part C Appendix). The implementation of the Northern Territory is difficult to evaluate as the inquests into the three deaths that occurred in Northern Territory prisons have not been completed or commenced.

Table 8.3 Breaches of Recommendations: Prison Custodial Health and Safety

View the table

Recommendation 150 - Equivalent Standard of Medical Care in Custody
That the health care available to persons in correctional institutions should be of an equivalent standard  to that available to the general public. Services provided to the inmates of correctional institutions should include medical, dental, mental health, drug and alcohol services provided either within the correctional institution or made available by ready access to community facilities and services. Health services provided within correctional institutions should be adequately resourced and be staffed by appropriately qualified and competent personnel. Such services should be both accessible and appropriate to Aboriginal prisoners. Correctional institutions should provide 24 hour access to medical practitioners and nursing staff who are either available on the premises, or on call.

A breach of recommendation 150 was only recorded when the first part of recommendation 150 was not implemented, where there was a not an equivalent standard of health care in the prison compared to the community. The remainder of the elements of recommendation 150 are reflected in recommendations 151-157.

In seven of the 43 cases there was sufficient information to conclude that prison health services were clearly below community standards. While there was little information available from Queensland coronial inquests, the lack of protocols for self-harm raise serious doubts as to quality of health care in that state's prison system.

Two cases in New South Wales indicated significant problems with Maitland and Mulawa Prison. In the case of a juvenile who died at Maitland Prison (6NSW) the deceased received no assessment on arrival at Maitland Prison, was put in a cell without a light switch or buzzer. The deceased was a juvenile, mentally unstable and it was his first time in an adult prison. He committed suicide three days later.

The level of medical services at Mulawa was put under scrutiny in the case of the woman who died at Mulawa Prison in 1994 (62NSW). Nursing staff did not act on information, provided by prison staff, regarding the deceased's health, for four days. The deceased was subsequently misdiagnosed by the prison doctor after she failed to consult her records. The nurse actually stated during the inquest, in response to the question 'this wouldn't happen in a proper hospital': 'It's extraordinary circumstances within a gaol, it's not like a hospital at all.' Nursing staff also failed to take appropriate action after being informed that the deceased was suffering from more than drug withdrawal. Although medical files on record with Corrective Services indicated a serious heart condition there was no indication that a stethoscope was ever used on the deceased. The Coroner noted that the State Director for Nursing Services for Corrections Health Services gave evidence that a large number of changes were being made at Mulawa Prison. In 1994, a House of Representatives Committee found that there were frequent attempts at suicide at Mulawa Prison while very few attempts occurred at Norma Parker Prison, the other women's prison in New South Wales. ¹⁵

Many of the deaths in Queensland indicated an inadequate standard of care. The rate of prison suicide was almost double the national average (see recommendation 152g). In eight of the nine investigated deaths there were no protocols for prisoners at risk of self-harm. In other cases in Queensland it was clear that the level of psychiatric care was also lacking (see recommendation 151). In two Queensland cases there was sufficient evidence (generally not available from Queensland coronial summaries) that the standard of care was below community standards (34QLD, 43QLD).

In the case of the man who died at Mobilong Prison (20SA), the Coroner found that due to 'an avoidable lack of information, confused communications, misinterpretation of instructions and lack of reasonable expedition' there was an unexcusable delay of three hours in the deceased receiving medical care for heart disease. He was certified dead on arrival at the hospital. While the case of the man who died at Yatala Labour Prison (60SA) indicates improvement in medical care, the six deaths in South Australia prisons in 1995 (half of the deaths since the Royal Commission) raise questions as to the adequacy of medical care. ¹⁶ Only one coronial inquest into these deaths has been completed. In the case of the 29 year old man who died at Adelaide Remand Centre the Coroner found serious problems with the record-keeping of the Prison Medical Service and the lack of protocols for urgent situations. In this case the deceased had heart disease.

There has only been one death in a prison in Tasmania, the man who died at Risdon Prison (30TAS). The Coroner found that the level of psychiatric services was inadequate. The Aboriginal Legal Service had also submitted that there was a lack of multi-prisoner cells in the prison hospitals but this was not addressed by the Coroner.

In Western Australia, four of the five deaths in prison have been investigated. However, in the three latter cases there was little consideration of prison health services: 33WA (Greenough Regional Prison); 56WA (Canning Vale Prison); and 57WA(Greenough Regional Prison). In the first case, the 35 year old man who died at Canning Vale Prison (23WA), the Coroner found that the 'medical attention given to the deceased was generally appropriate' although he noted that the deceased had no confidence in the Prison Medical Service. He further held that the fact of incarceration was not a significant factor in the death and 'he was at equal risk of a fatal heart attack if he was confined in prison or was living in the community'. The Coroner, however, did not address submissions of the ALS concerning information flows and screening procedures and the keeping of medical records. The deceased at the time was also trying to secure the visit of a independent medical practitioner. The Coroner responded to this issue by stating that 'the absence of freedom of choice is ...the real sanction for behaviour which is not acceptable to society'. This statement is contrary to recommendation 150 which calls for equivalent standard of care and access to community facilities. As coroners in New South Wales have repeatedly stated, the punishment is the deprivation of liberty. It is not the denial of adequate health care and medical services.

There have been three deaths in prisons in the Northern Territory. However, none of them has been the subject of a completed inquest.

While some Prison Medical Services have made efforts to improve their performance, and have made progress, they are still constrained by grossly inadequate funding.

Recommendation 151
The Commission recognises that there are limited numbers of psychiatrists with such experience. The Commission notes that, in many instances, medical practitioners who are or have been employed by Aboriginal Health Services are not specialists in psychiatry, but have experience and knowledge which would benefit inmates requiring psychiatric assessment or care.

Nine cases demonstrated that psychiatric services in a number of prisons were inadequate. The cultural appropriateness of psychiatric services in most prisons remains a continuing problem. The discussion under recommendation 152g(vi) also raises the issues of appropriate funding for mental health services within prisons.

A death in 1989 in New South Wales (6NSW) revealed an almost total lack of psychiatric facilities at Endeavour House (a juvenile institution) and Maitland Prison where the deceased died. In the recent case of the man who died at Parklea Prison (67NSW) in December 1994, the deceased was referred to the prison psychiatrist after being assessed on reception as a suicide risk. The deceased died four days later without having seen the psychiatrist. The lack of mental health facilities at Mulawa Prison is apparent in the case of the woman who died at Mulawa Prison (62NSW). It is noted in the Justice Under Scrutiny Report. ¹⁷

In Queensland the situation with regard to mental health is more alarming. In the case of the 17 year old juvenile who died at Sir David Longlands Prison (34QLD), psychiatric services were limited to a visiting semi-retired psychiatrist who kept no records of his visits with the deceased. The deceased was not seen by the psychiatrist after he first cut his wrist, as the psychiatrist was on leave and there was no replacement. The recent death at Sir David Longlands Prison (88QLD), although not investigated, indicates there may have been improvement in psychiatric services at this prison. The first two deaths at Townsville Prison (43QLD and 64QLD) indicate that there was no access to psychiatric services, the prison having being described as not fit for human habitation. In a recent case at Borallan Prison (74QLD) the quality of the psychiatric assessment is placed in question. The psychiatrist did not have the deceased's file and did not know of the deceased's Aboriginality. As noted above, Queensland has the highest rate of suicide in prison.

In South Australia, the ALRM has raised questions as to the availability of culturally appropriate psychiatric and medical care for patients after the death of a man at Port Augusta Prison (73SA) on 27 March 1995.

In Western Australia, the availability of psychiatric services is raised as an issue in the death at Greenough Regional Prison (33WA). The other cases did not provide sufficient information as to the level of services.

In Tasmania, in the case of the man who died at Risdon Prison (30TAS) the Coroner found that the services of psychiatrist, in addition to the psychologist, were required, and that psychiatric services needed to be urgently upgraded.

Full implementation of this recommendation requires psychiatrists who possess knowledge and experience of Aboriginal patients. In the case of the man who died at Long Bay Prison (72NSW) on 1 March 1995, the Coroner found recommendation 151 had been implemented, as the psychiatrist had twelve months experience in a Northern Territory community. This may or may not reflect sensitivity to Aboriginal culture. Given the marked over-representation of Aboriginal prisoners in the system specialised care is not an unreasonable expectation.

In the inquest into the death at Port Augusta Prison the director of a psychiatric facility for prison inmates stated:

[T]here is lack of psychiatric expertise within the gaol system itself; there are very few psychologists employed; there is not many available social workers for mental health cases; there is a shortage of meaningful programmes in gaols for anybody with a mental health illness; there are no liaison services, nursing liaison services, between psychiatry and mental health and prison.

Recommendation 152
That Corrective Services in conjunction with Aboriginal Health Services and such other bodies as may be appropriate should review the provision of health services to Aboriginal prisoners in correctional institutions and have regard to, and report upon, the following matters together with other matters thought appropriate:

The high number of both deaths in prisons and recommendations breached (150-157) raises questions as to whether there has been a sufficient review of the provision of health services. As is clear from discussion under recommendation 152c, none of the cases indicated any involvement of Aboriginal Medical Services. Coroners have called for comprehensive reviews of prison medical services in a number of cases (27NSW, 67NSW, 34QLD, and 78SA).

The various sub-paragraphs of recommendation 152 are considered separately below as to whether the various matters have been implemented.

Recommendation 152a
The standard of general and mental health care available to Aboriginal prisoners in each correctional institution;

The cases in which recommendation 152a was recorded as a breach include the cases in which there was a breach of recommendation 150. These were cases in which it could be clearly said that the standard of health care was clearly below community levels (6NSW, 62NSW, 34QLD, 43QLD, 20SA, 73SA and 30TAS).

As there is not a recommendation explicitly concerned with record-keeping in prisons, unlike recommendations 131 and 138 which concern record-keeping in police watch-houses, it will be discussed here. Coroners frequently criticised prison medical services for failing to keep proper records (4NSW, 27NSW, 44NSW, 62NSW, 67NSW, 14QLD, 34QLD, 43QLD, 60SA, and 78SA). It was criticised by the Western Australia ALS in another case (23WA). In the case of the man who died at Adelaide Remand Centre (78SA), the Coroner made the following recommendations:

That the Prison Medical Service develop a series of clear protocols to assist both medical and nursing staff to take appropriate action in urgent situations; and

That the Prison Medical Service review its systems in relation to record-keeping so that case notes are kept up-to-date and reviewed for that purpose at appropriate intervals.

Recommendation 152b - Culturally Appropriate Services
The extent to which services provided are culturally appropriate for and used by Aboriginal inmates. Particular attention should be given to drug and alcohol treatment, rehabilitative and preventative education and counselling programs for Aboriginal prisoners. Such programs should be provided where possible, by Aboriginal people.

A number of cases contained information indicating that the deceased was consuming drugs and alcohol in prison (10NSW; 46NSW; 56WA) or was withdrawing from drugs and alcohol (62NSW; 67NSW; 58QLD; 60SA; 33WA; 57WA ). As the majority of Australian prisoners commit offences under the influence of drugs and/or alcohol this number is likely to be much higher if more information were available.

In most cases it was difficult to determine the availability of culturally appropriate services, particularly those concerning drugs and alcohol. Drug and alcohol workers are now used by the prison services in New South Wales (see 67NSW) and there is a methadone program (10NSW).

In the case of the 22 year old man who died at Yatala Labour Prison (60SA) the Coroner found that a lack of programs was due to staff cutbacks. The provision of such services is necessary to prevent the high rates of recidivism for both Aboriginal and non-Aboriginal prisoners. Programs for Aboriginal prisoners need to be culturally appropriate to take into account the cultural circumstances of drug and alcohol use. These services not only assist individual prisoners, they are ultimately a service to the community at large.

Recommendation 152c Aboriginal Health Services
The involvement of Aboriginal Health Services in the provision of general and mental health care to Aboriginal prisoners.

Involvement of Aboriginal Health Services was apparent in none of the cases. In the case of the 20 year old man who died at Long Bay Prison (72NSW), the Coroner found that an Aboriginal health worker may have been able to diffuse a situation where the deceased had become very aggressive. However, he found that the staff did not know of the deceased's Aboriginality (despite recommendation 156) and there was no Aboriginal Welfare Officer (despite recommendation 174) to ensure liaison. Similarly, the Coroner, in the case of the 20 year old man who died at Arthur Gorrie Remand Centre (45QLD), found a lack of involvement of Aboriginal health workers.

Recommendation 152d - Facilities for Behaviourally Disturbed
The development of appropriate facilities for the behaviourally disturbed;

In a number of cases it was apparent that there were insufficient facilities for those with mental health problems. The Coroner in the Parklea Prison case (27NSW) recommended:

That in respect of persons at risk or with serious behavioural problems or who are mentally disturbed, short of certified current psychiatric experience, a Crisis Intervention Unit be established for their accommodation and care until they are certified fit to return the routine of prison.

In the case of the 20 year old man who died at Long Bay Prison (72NSW) there were insufficient safe cells and the deceased was moved back to a normal cell where he later committed suicide.

The appropriateness of prison safe cell facilities is to be questioned. ¹⁸ While the NSW Corrective Services Department has commented that there has never been a suicide in a safe cell, profile 72NSW is an example of a suicide immediately after release from a safe cell.

The Royal Commission cautioned against the over-use of observation or isolation cells as a response to persons identified as at risk. ¹⁹ They noted research which indicated that suicide is more common in segregation or isolation cells. It was commented that ward or dormitory accommodation may be more appropriate in many crisis situations. The Royal Commission stated that in cases of isolation a high degree of personal interaction must occur. The need for external stimuli is also obvious. The provision of a chalk board in the cells, often used for traditional painting, in Murgon Police Station in Queensland is a good example of such an approach.

The only program which falls squarely within this recommendation in New South Wales is the Special Care Unit at Long Bay Gaol, where inmates can voluntarily undertake programs in anger management and other matters. It is a pity that such a beneficial facility has such a small capacity, and that the prisoners who use the facilities are often released into environments which limit the benefits of the programme.

Concerns about safe cells are illustrated in three cases. In the case of the man who died at Risdon Prison (30TAS) the coronial report notes that deceased, after threatening to kill himself, was put in Category A Special Risk Classification. The following day he was downgraded to Category B where he was allowed a cigarette and a book. It is questionable whether the obvious restrictiveness of category A is necessary or useful. ²⁰

In the case of the 27 year old man who died at Townsville Prison (43QLD), the deceased committed suicide in the observation cell after being sent there for 'strict observation'. However, he was treated like other prisoners and only checked every half an hour.

The helpfulness of current safe cells was raised in the death at Yatala Prison (73SA) where the Coroner found prisoners were reluctant to inform custodial and medical officers of the 'at risk' behaviour of other prisoners because it may result in prisoners being placed in observation cells

Recommendation 152e - Information Exchange: External Health Agencies
The exchange of relevant information between prison medical staff and external health and medical agencies, including Aboriginal Health Services, as to risk factors in the detention of any Aboriginal inmate, and as to the protection of the rights of privacy and confidentiality of such inmates so far as is consistent with their proper care.

Recommendation 152e is related to Recommendation 157, as the latter concerns the securing of medical information by prison medical services from hospitals on reception and transfer. The cases in which this recommendations are breached are discussed under recommendation 157. They include three cases where there was no exchange of information on a visit to a hospital from a prison (59QLD, 78SA, 57WA) and three cases where the deceased had a significant medical history but this was not obtained from hospital or health services (37NSW; 74QLD; and 73SA). The need for 'risk flagging' system, as suggested by the Royal Commission and evident in recommendation 152e, is discussed under recommendation 157.

Recommendation 152e also concerns transfer of information from prison medical services to hospitals. In the case of the man who died at Mobilong Prison (20SA), there were a series of procedural breakdowns. The Coroner recommended that procedures be in place so that medical records accompany a prisoner on visits to a hospital.

Recommendation 152f - Information Exchange: Medical and Prison Staff 
The establishment of detailed guidelines governing the exchange of information between prison medical staff, corrections officers and correction administrators with respect to the health and safety of prisoners. Such guidelines must recognise both the rights of prisoners to confidentiality and privacy and the responsibilities of corrections officers for the informed care of prisoners. Such guidelines must also be public and be available to prisoners;

This recommendation was breached in 14 cases and is a recurring theme through the case profiles. The recommendation was breached in all jurisdictions except Northern Territory. In the Northern Territory inquests into three prison deaths have not been completed.

In ten cases, prison officers were not informed by Prison Medical Services as to the suicidal risk of the prisoner or remandee (10NSW, 27NSW, 63NSW, 67NSW, 47VIC, 30TAS, 13QLD, 14QLD, 34QLD, 59QLD). In some cases, prison officers were completely unaware of the deceased's suicide risk while in other cases Medical Services did not instruct prison officers as to appropriate action. If action had been taken, such as shared cell or safe cell, regular checks and removal of materials used for self-harm, these deaths may well have been prevented.

These communication breakdowns were graphically illustrated in the case of the 35 year old man who died at Parklea Prison (27NSW). Prison authorities did not follow the advice of the psychiatrist regarding the appropriate prison to which the deceased should be transferred. Prison officers subsequently failed to place the deceased in a shared cell due to his suicide risk. This was because the nurse did not communicate the reasons for such action because of concern for confidentiality.

In two cases, prison officers were unaware of the deceased's illness. In the death at Lithgow Prison (26NSW) prison officers were unaware of the deceased's epilepsy which required he share a cell in the event a fit occurred. In the case at Mobilong Prison (20SA) there were a series of mis-communications which resulted in long delays in taking the deceased to hospital for treatment of heart disease.

In the death at Port Augusta Prison (73SA), the Prison Medical Service did not inform custodial officers that the consequences of the deceased not taking his anti-depressant medication. They also did not pass on their concerns to doctors treating the deceased.

Communication failures from prison officers to nursing staff occurred in one case. In the case at Mulawa Prison (62NSW) prison officers had communicated to nursing staff that the deceased had endocarditis (heart disease). Nursing staff, however, did not properly record the information and there was a significant delay in their taking appropriate action.

A related issue is the communication by prisoners to custodial and medical staff of medical concerns about other prisoners. The Coroner in the death at Yatala Labour Prison on 17 March 1995 (60SA) noted that inmates did not trust the few social workers. In the death at Canning Vale Prison (56WA) the Coroner noted the adversarial nature of prison where prisoners would not inform on each other. In that case, two inmates knew the deceased was not rousable, after injecting himself with heroin. They did not inform prison officers as to his condition, even after the condition of one of the inmates, who had also taken the drug, was noticed by prison officers and an injection given to counteract the its effects.

The Coroner in a later death at Yatala Prison prison (73SA) noted that there was a 'code of silence' among prisoners which prevented them from informing officers as to at risk' behaviour of other inmates, particularly when this may have unpleasant consequences for the prisoners, including being placed in observation cells or being transferred to a psychiatric institution. While these latter concerns still need to be addressed (see discussion under recommendation 151 and 152d) relevant information needs to be passed onto medical staff. The Coroner recommended:

4. Continuing efforts should be made to encourage prisoners to pass on concerns or information they may have that a fellow prisoner may be at risk either to custodial officers, Aboriginal Liaison Officers, or any other appropriate person.

In correspondence with this office, the South Australian State Coroner addressed the 'code of silence' among prisoners and stated:

...at risk behaviour is not brought to the attention of correctional officers because the consequences for the prisoner are perceived as negative. In my opinion, this could prove to be the single most important factor in dealing with deaths in custody. If this attitude can be modified, and appropriate protocols developed for dealing with prisoners who have been so identified such that co-prisoners will not be deterred from reporting, in my opinion the number of deaths in custody will reduce substantially.²¹

An increased level of trust between prisoners, correctional staff and health staff is the nub of this recommendation. Prisoners will always fear informers, but it should be possible to ensure that the culture of silence does not carry over into the medical arena.

Recommendation 152g
The development of protocols detailing the specific action to be taken by officers with respect to the care and management of:

i. persons identified at the screening assessment on reception as being at risk or requiring any special consideration for whatever reason.

ii. intoxicated or drug affected persons, or persons with drug or alcohol related conditions;

iii. persons who are known to suffer from any serious illnesses or conditions such as epilepsy, diabetes or heart disease;

iv. persons who make any attempt to harm themselves or who exhibit, or are believed to have exhibited, a tendency to violent, irrational or potentially self-injurious behaviour;

v. persons with an impaired state of consciousness;

vi. apparently angry, aggressive or disturbed persons;

vii. persons suffering from mental illness;

viii. other serious medical conditions;

ix. persons on medication; and

x. such other persons or such situations as agreed.

Recommendation 152g(ii) - Drug or alcohol conditions. There was insufficient information on drug or alcohol related conditions of prisoners and related protocols to draw any conclusions. In many cases it was a contributing factor in suicide (67NSW, 60SA and 33WA) and deaths from natural causes (46NSW, 57WA and 62NSW). In a number of cases it was clear that no protocol existed for dealing with the conditions (60SA, 33WA, and 57WA) while the protocol was not followed in the other cases (46NSW and 67NSW).

In two cases prisoners died from drug overdoses (10NSW; 56WA). In the former case the Coroner found that the deceased should not have been permitted to share a cell with another prisoner who was also a heroin addict. In the latter case the Coroner found that monitoring of inmates was sufficient and that further monitoring would lead to greater than necessary incursion on their liberty.

Recommendation 152g(iii) - Serious illnesses, particularly heart disease, epilepsy and diabetes. In several cases, Medical Service knew of illnesses but no action was taken as a result. In other cases the issue of protocols did not arise as prison medical services and prison officers did not detect the illness - see discussion under recommendations 154 and 155.

The man who died at Lithgow Prison (26NSW) had AIDS and diabetes, and the latter illness was extremely difficult to control. He needed to be placed in a shared cell due to constant fits but this did not occur at Lithgow Prison. In the case of the man who died at Long Bay Hospital (37NSW), the Coroner stated it was inappropriate to transport the deceased, who had heart disease, in a car to hospital.

In sentencing the man who died at Prince Henry Hospital (ex Cooma Prison) (44NSW), the Judge stated that prison authorities should give special attention to the deceased's cancer. The Coroner found that the authorities failed to take an x-ray in 1991 and that the deceased should have immediately been seen by a doctor when his condition deteriorated in February 1993. The Coroner found these omissions did not contribute to the deceased's death. In the case of the man who died at John Moroney Prison (46NSW), the Coroner recommended that staff should regularly monitor the anti-epileptic drug levels of epileptics to ensure they are in the therapeutic range. In the case of the woman who died at Mulawa Prison (62NSW) nurses and doctors failed to take appropriate action once they learnt of the deceased's endocarditis.

In the profile of the detainee who died in the Metropolitan Remand centre in Coburg, Victoria in 1993 (48VIC), the Coroner found irregularities in the procedures for dispensing epilepsy medication. He made no finding as to whether deficient recording of refusal to take epilepsy medication contributed to the death.

In the case of the man who died at Adelaide Remand Centre (78SA), the Coroner recommended that a series of protocols be developed to assist both medical and nursing staff to take appropriate action in urgent situations.

Recommendation 152g(iv) - Self-harm. The rapid increase in the number of suicides in prison requires a closer analysis of the deaths. Table 8.2a shows the number of self-inflicted deaths in prisons compare to the number of total deaths in prison.

In Queensland 81 per cent of prison deaths have been from suicide. In South Australia it is 56 per cent while in New South Wales and Western Australia it is respectively 26 per cent and 33 per cent. Comment cannot be made on trends in other States and Territories as there has been an insignificant number of deaths in prison.

Table 8.2a Suicide in Prison

The high numbers of self-inflicted deaths in Queensland and South Australia raises questions as to the development and effectiveness of protocols. Table 8.2b provides this information for the 21 cases where sufficient information on the circumstances of the death is available (coronial findings or legal submissions). The Table shows the number of breaches of this recommendation in each state and breaks them into three categories: (i) no protocol; (ii) protocol was unsatisfactory; and (iii) the protocol was not followed.

Table 8.2b Suicides in Prison: Protocols for Self-harm

In eight of the nine cases in Queensland there were no protocols for prisoners at risk of self-harm. In only five of these cases (14QLD, 34QLD, 45QLD, 64QLD and 74QLD) was this noted by the Coroner. Queensland coroners were restrictive in what they have looked at, but the issue falls squarely within their narrow scope.

In three cases it was apparent from the information available that no protocol at all existed (13QLD, 43QLD and 59QLD). In the remaining case of the juvenile who died at Lotus Glen Prison (22QLD) the deceased was given adequate care. He had the AIDS virus and was treated as a special case after petitions from the nurses at the prison.

However, it should be noted that in the case of the man who died at Arthur Gorrie Remand Centre (45QLD) the Coroner stated that 'steps had been taken to implement protocols for the care and safety of inmates' at the Arthur Gorrie Remand Centre. He commented that the introduction of such protocols would potentially benefit all prisons in Queensland.

The cases in New South Wales indicate the existence of such protocols, except for the early case of the juvenile who died at Maitland Prison (6NSW). However, coroners in three cases held that the protocol was not satisfactory. In the case of the 47 year old man who died at Parklea Prison (27NSW) the Coroner found that procedures were not followed because nursing staff withheld information from prison staff for reasons of confidentiality. In the case of the 24 year old man who died at Long Bay Prison (63NSW) the Coroner found that the system should be altered whereby: (i) prison officers are informed of prisoners are at risk; (ii) prison officers double check cells on let-go's for 'at risk' inmates who hide in the cells; and (iii) that sufficient resources should be allocated for this 'double checking' purpose. The unsatisfactory nature of the protocol in another case (72NSW) is discussed in conjunction with the Tasmanian case below. The protocol for prisoners at risk of self-harm was not followed in the case of the 19 year old man who died at Parklea Prison (67NSW). The reception nurse and Drug and Alcohol Worker did not properly inform prison officers as to 'risk status' of the deceased. Furthermore, the deceased was not visited by a psychologist despite a referral being made at the reception assessment.

The cases in South Australia and Western Australia raise issues concerning the satisfactory nature of protocols. In the cases at Yatala Labour Prison (60QLD, 68QLD) there were obvious hanging points (further discussed in recommendation 165) and in the earlier case infrequent checks of prisoners. In the case of the man who died at Greenough Regional Prison (33WA) the Coroner found that prison medical staff were justified in not classifying the deceased as 'at risk' despite the fact the deceased was placed in special 'at risk' observation clothing after returning from hospital. The Coroner found that the clothing was just a formality. However, this practice raises questions though as to the effectiveness of the procedure and leaves doubts as to whether officers regarded the deceased as being 'at risk.'

The cases of the 20 year old man who died at Long Bay Prison (72NSW) and the man who died in Risdon Prison (30TAS) raise the problems of re-classification. The former Aboriginal prisoner had attempted suicide twice within a week of imprisonment. After a week he was downgraded and put in a cell by himself where he committed suicide. Similarly, the latter prisoner was downgraded in the prison hospital from Category A to C and within 3-4 days he committed suicide.

In the profile A7QLD, involving a death in a mental institution, the investigation team made the recommendation that 'a buddy system be introduced in cases where a patient is at risk of self-harm.' This recommendation is the type which the Royal Commission contemplated.

Recommendation 152g(v) - Angry, aggressive and disturbed person. In three cases the deceased were overtly angry and aggressive (72NSW, 13QLD and 34QLD). Each had a history of mental illness. In another case the deceased was frightened and disturbed (68SA) but it is unknown whether the deceased suffered from mental illness.

In the case of the 21 year old man who died at Rockhampton Prison (13QLD) the deceased was hypersensitive. Notes on the psychologist's file indicated the deceased would react badly to violence. No procedures were put in place as a result. On the day of his death the deceased had two heated exchanges and struggles with officers who did not know of the deceased's hypersensitivity. This death triggered off further anger and unrest amongst inmates and was a contributing factor in the suicide of a Aboriginal prisoner the following day (14QLD).

The 17 year old juvenile who died at Sir David Longlands Prison (34QLD) was in a 'acutely disturbing' state. He was withdrawing from amphetamines, severely depressed and upset over an additional sentence preventing him returning home at Christmas. He had asked the senior psychologist for anger management counselling but this was refused. The deceased destroyed his cell on 17 December 1991 and committed suicide on 22 December. The Coroner recommended that Management Plans for young offenders be introduced.

The 20 year old man who died at Long Bay Prison (72NSW) had a personality disorder and was extremely abusive of staff. He was put in seclusion in an observation cell. He was later placed back in his own cell, when other suicidal prisoners needed to be placed in the cells. He subsequently committed suicide. The Coroner recommended that health services be reviewed with a development of protocols dealing with action to be taken in the care of apparently angry, aggressive or disturbed persons under Recommendation 152(g)(v) of the Royal Commission.

The 18 year old man who died at Yatala Labour Prison was placed in a maximum security section (68SA). He had been sentenced to a nine month sentence by a Children's Court, and orders for his transfer to a more appropriate youth training facility had been lost. He was described by witnesses as 'distressed, agitated and frightened,' however no action was taken.

All of these deaths involved young men at the beginning of their sentence. The need for a transition period (R175), Aboriginal Welfare Officers (R174) and sufficient mental health care is apparent.

Recommendation 152g(vi) - Mental illness. In 10 of the 21 investigated cases of suicide in prison the deceased had mental illness. In most of the cases the mental illness was depression. In a few cases it was schizophrenia and in one case personality disorder.

Five of the 10 cases only raised issues of self-harm (33WA, 14QLD, 22QLD, 72NSW), anger (72NSW) and taking of medication (73SA). However, five cases indicated systemic problems in dealing with mentally ill prisoners (13 QLD, 34QLD, 43QLD, 59QLD, and 74QLD). In these cases prison medical authorities did not have information on the deceased's condition, medication was not given or dosages were insufficient or too much, the deceased was not given sufficient counselling or visits from psychiatrists and observation of the deceased was insufficient. See the discussion under recommendation 151 on the need for greater expertise and services for prisoners with mental illness.

Recommendation 152g(vii) - Other serious medical conditions. The juvenile who died at Lotus Glen (22QLD) had AIDS. A protocol for the deceased's care was established. However a 'misunderstanding' caused the cancellation of visits by an AIDS counsellor. The deceased was also isolated, as prison officials believed other inmates would not share a cell with the deceased. However, inmates reportedly stated they would be willing to share a cell with the deceased. The cancellation of the visits and isolation were held to be contributing factors to the deceased's suicide. There was another case where a prisoner had AIDS (26NSW). However, the more significant issue in that case was the deceased's diabetes condition which was extremely difficult to control.

Recommendation 152g(viii) - Persons on medication. A number of cases raised issues concerning taking of medication for epilepsy, diabetes, heart disease and mental illness (34QLD, 59QLD, 74QLD and 73SA).

In the four cases concerning epilepsy the deceased did not take medication (19NSW, 46NSW, and 48VIC). In the former two cases this was the immediate cause of death (19NSW and 46NSW).

In the Victorian case the Coroner made an open finding as to whether a failure to take medication, present in the deceased's blood in sub-therapeutic levels contributed to the death. The Coroner in the two latter cases recommended better recording of times when a prisoner refuses to take medication.

In one case the deceased had been storing the epileptic drugs to consume in larger doses as well as trading the medication for illegal drugs (46NSW). The Coroner recommended:

1. Where persons are known epileptics medical staff should regularly monitor them to ensure their anti-epileptic drug levels are within the therapeutic range. In any case, where such a prisoner is found to be intoxicated by a drug or otherwise, such monitoring should be compulsory; and
2. Practices and procedures adopted by Prison Medical Service for prescription and supply of drugs should be reviewed to ensure that prisoners cannot store and trade drugs. Prisoners to be advised of the importance of taking their medication as prescribed and an acknowledgment of receipt of such advice be appropriately recorded.

Similarly in two cases involving diabetes and heart disease there were questions over whether the deceased took medication. In the case of the man who died at Long Bay Prison (52NSW) the deceased had signed a declaration stating he did want his medication. The family raised the issue of whether this was for one day or permanently. The Coroner found that since the deceased knew the procedures for obtaining medication it had been his responsibility. In the case of the man who died at Broome Regional Prison (85WA) it was unclear whether the deceased had been given his medication for heart disease.

In the cases concerning mental illness the issue was the level of drugs prescribed. In the case of the juvenile who died at Sir David Longlands Prison, the family believed that the deceased was being over-sedated (34QLD). In the case of the man who died at Borallon Prison (74QLD) the family reported that the deceased's medication was at a lower level than the deceased had received before prison. In the death at Arthur Gorrie Remand Centre (59QLD) the deceased was not given his medication on return from hospital. There was a delay in records being transferred from the hospital and on arrival they were not read by nursing staff (59QLD).

Recommendation 153 
That:

1. Prison Medical Services should be the subject of ongoing review in light of experiences in all jurisdictions;
2. The issue of confidentiality between prison medical staff and prisoners be addressed by the relevant bodies, including prisoner groups; and
3. Whether administrative model for the delivery of prison medical services is adopted, it is essential that medical staff should be responsible to professional medical officers rather than to prison administrators.

Case profiles in Queensland indicated that a review of Prison Medical Services had probably not occurred in accordance with recommendation 153a.

The recommendation was listed as breached in the case of the 27 year old man who died at Townsville Prison (43QLD). The Corrective Services Commission attempted to avoid publication, or production to the Coroner, of an internal investigation into the death which showed serious deficiencies in procedures. It was also listed as breached in the case of the 17 year old juvenile who died at Sir David Longlands Prison (34QLD). In that case the Coroner made a comprehensive examination of the prison medical service and found that it operated on inadequate resources and procedures were deficient.

As stated under recommendation 152, a review of all Prison Medical Services is urgently needed in light of the increasing number of avoidable deaths in prison.

Recommendation 153b is linked to recommendation 152f as both concern the exchange of medical information concerning prisoners and issues associated with confidentiality. In most of the cases, the problem concerned the lack of procedures or the failure of staff to follow procedures. However, in a number of cases the information was not exchanged between medical and prison officers because of confidentiality. This occurred in three New South Wales cases in 1991 and 1992. Coroner Hiatt, in a number of non-Aboriginal deaths in custody and in the case of the 24 year old man who died at Parklea Prison (10NSW), recommended that prison officers should have access to prisoner's medical files to facilitate proper care of prisoners. The lack of access to relevant information was still evident in the case of the man who died at Lithgow Prison (26NSW) and in the case of the 47 year old man who died at Parklea Prison (27NSW) Coroner Hiatt found that his earlier recommendations had not been implemented. The nurse had not explained to the prison officer why the deceased needed to placed in a shared cell because of confidentiality and as a result the prison officer did not act upon the advice. Subsequent cases in New South Wales indicate that protocols are now in place. This can be seen in the death at Parklea Prison (67NSW). However, in that case the protocol was not followed.

In the case of the man who died at Geraldton Regional Hospital (57WA) the Coroner made a number of recommendations to ensure a balance between confidentiality and the dissemination of relevant information. He recommended that:

1. At the time of admission to prison during the initial medical check, prisoners be invited to sign release forms in relation to medical history 'directed to any and all medical practitioners he has been treated by' (although this should not be compulsory with prisoners able to decline).
2. Medical files kept at 'the Prison Health Service' to be sent with prisoners when they are transferred to or being treated at a hospital. To address the issue of confidentiality, the file should be sealed so the prisoner and accompanying prison officers do not have access to it, and returned in the same manner when the prisoner is discharged or no longer being treated by in hospital.

The cases indicated that in most jurisdictions medical staff were responsible to the Department of Health in accordance with recommendation 153c.

Recommendation 154 - Aboriginal Health Training for Prison Medical Services

1. All staff of Prison Medical Services should receive training to ensure that they have an understanding and appreciation of those issues which relate to Aboriginal health, including Aboriginal culture, and life-style so as assist them in their dealing with Aboriginal people;
2. Prison Medical Services consult with Aboriginal Health Services as to information and training which would be appropriate for staff of Prison Medical Services in their dealings with Aboriginal people;
3. Those agencies responsible for the delivery of health services in correctional institutions should endeavour to employ Aboriginal persons in those services.

The Royal Commission found that Aboriginal people were more susceptible to death from natural causes, particularly heart disease, epilepsy and diabetes. This is also true of the post-Royal Commission period. Chapter 3.6 showed that Aboriginal people in prison are twice as likely as non-Aboriginal people to die from natural causes. It was shown that Aboriginal people were slightly more likely to commit suicide.

It was frequently found (12 cases) that medical staff had insufficient cross-cultural health training in accordance with recommendation 152a. The lack of understanding of these issues can also be seen under recommendation 133 (police officers) and recommendation 155 (prison officers).

In seven cases Coroners explicitly noted the need for prison medical staff to have training in the susceptibility of Aboriginal people to certain diseases. Five cases involved heart disease (62NSW, 22QLD, 34QLD, 78SA, and 57WA) and two cases involved suicide (67NSW and 72NSW). In four other cases of heart disease (39NSW, 55QLD, 20SA) and a case involving suicide (13QLD) it was clear that prison medical staff had insufficient training.

In properly implementing 153a correctional authorities will need to involve Aboriginal Health Services in the training in accordance with recommendation 153b. Omission of Aboriginal Health Services was noted by Coroner Abernathy in the case of the 20 year old man who died at Long Prison (73NSW) and he recommended that greater involvement occur.

In a number of the above cases coroners have recommended that more Aboriginal staff be employed by Prison Medical Services. Coroner Abernathy initially suggested more Aboriginal staff be employed in the case of the 24 year old man who died at Long Bay Prison (63NSW). He later recommended there be urgent compliance with recommendation 154 in the later case of the 20 year old man who died at Long Bay Prison (72NSW).

In the case of the 21 year old man who died at Arthur Gorrie Remand Centre (45QLD) the Coroner suggested that Aboriginal counsellors and nurses be available, particularly on assessment.

Recommendation 155 - Aboriginal Health Training for Prison Officers
That recruit and in-service training of prison officers should include information as to the general health status of Aboriginal people and be designed to alert such officers to the foreseeable risk of Aboriginal people in their care suffering from those illnesses and conditions endemic to the Aboriginal population. Officers should also be trained to better enable them to identify persons in distress or at risk of death or harm through illness, injury or self-harm. Such training should also be taken in relation to the matters which are to be the subject of protocols referred to in Recommendation 152g.

In a number of Queensland and Western Australian cases it was clear that prison officers did not have sufficient training to identify Aboriginal prisoners at risk. In the case of the 17 year old juvenile who died at Lotus Glen Prison (22QLD) the Coroner recommended that ongoing tuition be given to correctional staff, especially to address the problems of inmates with AIDS and inmates of Aboriginal culture. In the case of the 17 year old juvenile who died at Sir David Longlands Prison (34QLD) the Coroner recommended that all staff attend properly authenticated courses for the prevention of suicide and that all staff read and familiarise themselves with the Recommendations of the Royal Commission into Aboriginal Deaths in Custody.

In three cases prison officers did not act on information they had received regarding the deceased's suicidal tendencies (14QLD, 64QLD and 33WA). In the case of the 27 year old man who died at Townsville Prison (43QLD) the deceased who had schizophrenia was upset, barricaded himself in his cell and had set fire to it and was generally displaying irregular behaviour. Medical records documenting the deceased's suicidal tendencies had not been forwarded to the prison, however, prison officers should have considered whether the deceased was suicidal and taken appropriate action.

In two cases involving heart disease (55QLD and 57WA) it is to be questioned whether prison officers should have been able to detect the signs of heart disease from the symptoms the deceased was displaying.

Recommendation 156 - Medical Assessment on Reception 
That upon initial reception at a prison all Aboriginal prisoners should be subject to a thorough medical assessment with a view to determining whether the prisoner is at risk of injury, illness or self-harm. Such assessment on initial reception should be provided wherever possible by a medical practitioner. Where this is not possible, it should be performed within 24 hours by a medical practitioner or a nurse. Where such assessment is performed by a trained nurse rather than a medical practitioner then examination by a medical practitioner should be provided within 72 hours of reception or at such earlier time as requested by a nurse who performed such earlier assessment, or by the prisoner. where upon assessment by a medical practitioner, trained nurse or such other person as performs an assessment within 72 hours of prisoners' reception it is believed that psychiatric assessment is required then the Prison Medical Service should ensure that the prisoner is examined by a psychiatrist at the earliest possible opportunity. In this case, the matters referred to in Recommendation 151 should be taken into account.

This recommendation requires at a minimum: (i) assessment by a nurse within 24 hours of reception at prison; (ii) assessment by a doctor within 72 hours of reception; and (iii) referral and examination by a psychiatrist. It also requires effective screening forms for reception nurses. There have also been a number of recommendations from Coroner's and Aboriginal groups concerning reception assessment teams.

This recommendation was most frequently breached in New South Wales where it is Correctional Health Services policy not to utilise doctors in the reception process (see 71NSW). In a number of deaths this policy may well have been a contributing factor. In the case of the man who died at Broken Hill (71NSW) and the woman who died at Mulawa Prison (62NSW) heart disease was not detected as nurses simply took information proffered by the deceased. If a medical practitioner had examined the deceased their condition very likely would have become apparent. In two deaths at Prince Henry Hospital (ex Long Bay) (37NSW) and (ex Cooma Prison) (44NSW) heart disease and cancer respectively could have been detected at an early stage had the deceased been seen by a doctor within seventy-two hours of admission.

In the death at Maitland Prison (6NSW) the deceased was not seen by a nurse on reception and later committed suicide. In the death at Parklea Prison (67NSW) the deceased was not seen by a psychiatrist even after being referred (see recommendation 151).

In the death at Mobilong Prison (20SA) the deceased's heart disease was not detected despite the deceased displaying symptoms. In the death at Borallon Prison (74QLD) and Yatala Labour Prison (60SA) the adequacy of the assessment is doubtful given the failure to identify the deceased as Aboriginal and his suicidal ideations.

Implementation of this recommendation is essential. Prison authorities need to know the medical state of people for whom they have responsibility. It is essential to the discharge of that responsibility.

This view was expressed by a doctor in cross-examination during the inquest into the death at Mulawa Prison (62NSW):

Q. ... your view is that there should be a full examination by a doctor rather than a nurse whenever an inmate comes into prison?

A. Yes I do, because otherwise you don't know what you are landed with. If you're going to take care of them at a later time you need a basis.

Q. Can I just ask you why a doctor rather than a nurse?

A. Because I think that a nurse is not able to evaluate the health of a sick patient, or of a patient with the same degree of expertise as a medically trained person.

Q. Because it's not a nurse's role to diagnose illness is it?

A. Well it seems to be a wavy line at the moment in terms of some situations in some hospitals, but as a general rule I don't know of a hospital that in - and I'm talking about Australia - where there is not a full medical examination of a patient when it comes in, and neither do I know of the armed forces, or the public facilities that don't have a full medical examination by a qualified medical officer.

Q. And you'd make a recommendation to the Coroner that happens throughout the Prison Medical Service.

A. Absolutely yes.

New South Wales and Western Australia only provide nurses for assessment upon reception. ²² In juvenile detention centres in Queensland assessment by a medical practitioner may not occur for seven days. The implementation reports of Tasmania and Northern Territory leave ambiguity as to what personnel undertake assessment.

The adequacy of assessment forms was raised in three cases. In the case of the man who died at Broken Hill Prison (71NSW) the Coroner recommended that the Corrections Health Service revises the Health Reception Assessment form by including questions which focus on symptoms and signs of heart disease.

The form used by the drug and alcohol worker in the case of the man who died at Parklea Prison (67NSW) was provided to this Office by the Corrections Health Service. The form appears deficient in a number of respects. The form relies on a system of high risk ratings if a detainee displays certain behaviours, or has a certain history. It places too much emphasis on self-report of suicidal ideation, particularly if a prisoner is under the influence of drugs or alcohol, as the deceased was in this case. ²³ The deceased was asked whether he was feeling in control. The drug and alcohol worker noted that he responded positively, but that his response could be explained by the fact that he had recently taken 30-40 rivotril tablets. The danger period is when the effects of the drugs wear off. The way the form was structured, he was given only a medium risk rating on that point. Further, the deceased had been in a juvenile detention facility some years earlier (where he had attempted suicide at the age of thirteen). The question on the form was whether he had been previously imprisoned. Accordingly, another automatic high risk rating, which was supposed to trigger protocols for further assessment, was not noted on the form.

The form has also been criticised by the Deaths in Watch Committee (A8NSW) in a recent case at Bathurst Prison which occurred after this Report's cut-off period. A Forensic Consultant, in an advice to the Committee, noted that the screening form does not provide information on recent personal conflicts. The deceased in two cases (33WA, 60SA) both entered prison after a 'personal conflict' situation in their families. A number of other self-inflicted deaths occurred after personal conflicts, although these conflicts occurred after the reception procedure (67NSW, 34QLD, 74QLD, 82SA). The Deaths in Watch Committee (NSW) also recommended that some of the questions used in the Corrections form be deleted and put in the Corrections Health reception form.

The personnel involved in reception has been raised in a number of cases. In the case of the 21 year old man who died at Arthur Gorrie Remand Centre (45QLD) the Coroner suggested that

1. The role of an Aboriginal whether in the capacity of a counsellor or as an advisory member of the high risk assessment team be utilised specifically where the inmate under assessment is of Aboriginal descent;
2. An Aboriginal nurse, if available, be present during medical examinations and assessments of Aboriginal inmates and the services of a male nurse be utilised wherever practicable; and
3. That where practicable members of an Aboriginal family be consulted when ascertaining the medical, psychiatric or psychological profile of an Aboriginal inmate.

The Aboriginal Deaths in Custody Watch Committee (NSW) has recently made a number of recommendations concerning the reception committees after a recent death at Bathurst Prison (A8NSW). In that case the assessment was not done by a worker with mental health training. The Committee recommended:

1.3 That Corrections Health immediately assess the qualifications of all personnel involved in the assessment/screening of inmates. Only psychologically trained personnel will be utilised for this task.

1.5 That strong recommendation is made that where a family member is already incarcerated within the gaol complex, then that family member - if willing - be allowed to sit in on the assessment/screening process - strictly as an observer only. Recognition must be made of the extended family situation of Aborigines.

1.6 That failing a family member being present, or unwilling to assist, then a member of the Aboriginal Inmate Development Committee be allowed to fill that role.

1.7 That investigations must begin immediately as to the legal involvement of any family member or Aboriginal Inmate Development Committee member who fulfils this role.

Presumably, the involvement of Aboriginal Welfare Officers would be invaluable in the reception process (see recommendation 175).

Recommendation 157 - Securing Comprehensive Medical History
That, as part of the assessment procedure outlined in Recommendation 156, efforts must be made by the Prison Medical Service to obtain a comprehensive medical history for the prisoner including medical records from a previous occasion of imprisonment, and where necessary, prior treatment records from hospitals and health services. In order to facilitate this process, procedures should be established to ensure that a prisoner's medical history files accompany the prisoner on transfer to other institutions and upon re-admission and that negotiations are undertaken between prison medical, hospital and health services to establish guidelines for the transfer of such information.

1. This recommendation provides for the securing of a comprehensive medical history from:
   
   1. a prison from which the deceased has just been transferred;
   2. a hospital from which the deceased has just been transferred;
   3. prior periods of imprisonment; and
   4. prior treatment from hospital and health services.

The first category is presumably the most straightforward but in three cases medical files did not accompany the deceased on transfer between prisons (6NSW, 27NSW and 43QLD). The deceased in each case had records of self-harm but the receiving prison had no knowledge of this information.

In three cases the deceased had been temporarily transferred to a hospital but records of the visit were not taken back to the prison. The Director of John Oxley Memorial Hospital gave evidence in the case of the man who died at Arthur Gorrie Remand Centre (59QLD) that he had not been approached by the Queensland Corrective Services Commission or Commissioner for Health to develop protocols for transfer of information. This is despite the hospital being the only hospital used by the prison (see also recommendation 152e). In the case of the man died at Geraldton Regional Hospital (57WA) and Adelaide Remand Centre (78SA) the Coroner found that information about the deceased's health was not transferred back to the prison from the hospital.

In a number of cases it was evident that Prison Medical Services did not have medical files from earlier periods of imprisonment. In the case of the woman who died at Mulawa Prison (62NSW) the deceased had been diagnosed some years earlier by a prison doctor as having endocarditis. When examined by the same doctor in 1994 the doctor did not consult her earlier files which would indicated the source of the deceased's symptoms. In the case of the 23 year old man who died at Prince Henry Hospital (37NSW) the deceased's medical records were not transferred during his various times in prison. In the case of the man who died at Adelaide Remand Centre (78SA) the deceased had a voluminous prison medical history but this was ignored by staff.

In three cases it was clear that no attempt had been made to obtain medical records from prior visits to hospitals and health services. In the cases of the 23 year old man at Prince Henry Hospital (37NSW) and the man who died at Broken Hill Prison it would appear that the Prison Medical Service was unaware of the deceased's heart disease and prior visits to hospitals. In the case of the man who died at Borallon Prison (74QLD) the Coroner recommended that medical and psychological staff institute precautionary monitoring so they can have all relevant medical and psychiatric information for assessment of prisoners.

It was the institution of such a precautionary system which the Royal Commission favoured. They discussed the computerised system which had been developed in the Northern Territory. The Department of Health and Community Services would be provided with a list of the names of remand and freshly sentenced prisoners. ²⁴ The Department would then notify the prison if the prisoner was 'at risk' in terms of physical or mental health.

It is clear that no other State or Territory had implemented such a system. Coronial recommendations for a precautionary system (74QLD) and computerisation of record systems (78SA) should be given urgent consideration.

There was also a breakdown in communication between the judicial and prison systems in the case of the 64 year old man who died at Prince Henry Hospital (44NSW). The Judge in sentencing the deceased recommended that prison authorities give early and particular attention to the deceased's asbestosis. However, there was no evidence that this recommendation ever reached the Cooma Prison Medical Service.

4. Custodial Health and Safety: General

This section concerns recommendations which were designed to improve custodial health and safety conditions for detainees in police or prison custody. The recommendations reflect the duty of care that is owed to all detainees by custodians. Their breach is a serious matter.

Table 8.4 lists the frequency of breaches. The most frequently breached recommendation was 165 which concerns the removal of hanging points and items that can be used for self harm within cells. Other frequently breached recommendations include the provision of immediate resuscitation following a suicide attempt, the availability of resuscitation equipment and persons trained to operate it, ongoing training in first aid and resuscitation, and the seeking of medical attention when a detainee is in distress.

Table 8.4 Custodial Health and Safety: General

Recommendation 158 - Immediate Resuscitation following a Suicide Attempt
That, while recognising the importance of preserving the scene of a death in custody for forensic examination, the first priority for officers finding a person, apparently dead, should be to attempt resuscitation and to seek medical assistance.

There were eleven cases in which there resuscitation was delayed due to either to lack of training, lack of resuscitation equipment or the inability to open cell doors.

The Coroner recommended training in resuscitation techniques following the death of a young man in the police cells in Ceduna in South Australia (1SA). No resuscitation was attempted in this case. The man had not been checked for two hours prior to his death, so it was not possible to determine accurately how long he had been hanging. A Coroner found in a Victorian case that resuscitation ideally should have been attempted, and that there was a slight possibility that if an attempt was made it might have succeeded (31VIC).

The Coroner recommended training in first aid and resuscitation procedures after the death by hanging of a 17 year old young man in Sir David Longlands Prison in Queensland (34QLD). Resuscitation was not attempted in that case until ambulance officers arrived. After the death by hanging of a 27 year old man at Borallon Correctional Centre (74QLD) prison officers had to run back to the office of the operations manager to get the key to the safe in B block, then gain access to B block, open the safe, obtain the unit and cell keys and eventually gain access. The Coroner recommended that the security system be changed to reduce this delay in future.

Several Coroners did not note the breach of this recommendation in a number of other cases in which resuscitation was avoidably delayed. In a death from epilepsy at Long Bay Gaol in NSW (19NSW) the deceased was found when prison officers opened his cell in the morning. No resuscitation was attempted, although resuscitation equipment was later brought. In the case of the man who died in the back of a police van at Moorebank (42NSW) resuscitation was not attempted because no equipment was available. Given the lack of equipment, the Coroner found that the decision not to attempt resuscitation was reasonable because the deceased was known to have had a drug history and because there was a discharge from his mouth. In a Queensland case the Queensland Corrective Services Commission internal investigator's report commented on the failure to attempt resuscitation, but the Coroner did not address the issue (43QLD). The prison officer did not have keys or a radio.

In the case of a man who died of a heart attack at the Port Headland Lockup in Western Australia (2WA) in 1989, the failure to attempt resuscitation was justified in the Coroner's report on the basis that 'it was the opinion of both officers that the deceased had been dead for some minutes.' There is a distinct possibility that after some minutes resuscitation could have been successful. Prisoners at the inquest gave evidence that there was a delay in attempting resuscitation following the discovery of the man who died at the East Perth Lockup (65WA).

There were a disturbing number of deaths in which resuscitation could not be immediately attempted because officers conducting checks of the cells did not carry keys to allow them access to the cells. The cases in which this was apparent included the deaths of a twenty one year old man and a twenty four year old man at Rockhampton Correctional Centre (13QLD, 14QLD). The failure to carry keys delayed access to the deceased on the evening of the first suicide, and the next night the same problem occurred. In the case of the 17 year old young man who died in Sir David Longlands Prison (88QLD) there were claims that the cell mate detected a pulse when officers arrived, but that the officers refused to pass a knife through to the cell mate and they could not open the door for approximately fifteen minutes because they did not have keys.

Recommendation 159 - Availability of Resuscitation Equipment
That all prisons and police watch-houses should have resuscitation equipment of the safest and most effective type readily available in the event of emergency and staff who are trained in the use of such equipment.

Police custody cases revealed the greatest number of identified deficiencies in resuscitation equipment and training for its use. In the case of the young man who died in a police van at Moorebank (42NSW) the Coroner criticised the lack of resuscitation equipment. The Coroner found that only one mask was located, and that this mask did not have a valve. In the case of the woman who died in Brisbane Lockup (38QLD) the cursory coronial findings do not give any details of the basis for the Coroner's recommendation. However, a Criminal Justice Commission investigation into the police involvement revealed that the only officer who held a certificate in first aid was unable to operate the air viva device, which supplements or takes the place of mouth to mouth resuscitation.

The records of the case of the 54 year old man who died at Deniliquin in New South Wales (76NSW), and who the Coroner found had jumped off a bridge to avoid police, indicated that cardio pulmonary resuscitation (CPR) was not attempted until ambulance officers arrived, as police did not have resuscitation training or equipment. The Victorian case of a woman who died in a police van outside the Bendigo Police Station (36VIC) revealed that a senior constable was unable to locate a mouth piece for further CPR either in the watch-house or in any of the vehicles at the station. In the case of the man who died in Bendigo Police Station (31VIC) the coronial transcript reveals that resuscitation equipment was not available in the police cells. The transcript also revealed that the cells were still not equipped with resuscitation devices a year later when the coronial inquest was held. Finally, it appears that in the case of the man who died at the East Perth Lockup (65WA) no resuscitation equipment was available close to the holding cell.

The problem was also apparent in prison deaths. In the case of the 17 year old who died in the Sir David Longlands Prison in 1991 (34QLD) the Coroner recommended 'the attendance of all staff at approved courses in first aid and resuscitation techniques, which should include the requirement that a proficient standard be attained in the use and maintenance of relevant equipment employed.'

The Coroner refused to make a finding that resuscitation should have been attempted in the case of the man who died at Risdon Gaol (30TAS), but he noted the absence of a defibulator. It was recommended in the case of a death at Broken Hill prison (71NSW) that prison officers have access to air viva devices. The case of a 19 year old who died of epilepsy in Long Bay gaol (19NSW) involved prison officers who were untrained in first aid, and had to wait for medical help.

Recommendation 160 - Ongoing Training in Resuscitation
That:

1. All police and prison officers should receive basic training at recruit level in resuscitative measures, including mouth to mouth and cardiac massage, and should be trained to know when it is appropriate to attempt resuscitation; and
2. Annual refresher courses in first aid be provided to all prison officers, and to those police officers who routinely have the care of persons in custody.

In the case of the man who died in Ceduna Police Station (1SA) police did not attempt resuscitation. The Coroner remarked 'that first aid training would ultimately be desirable.' The Coroner recommended in the case of the death of the woman at the Brisbane Watch-house that recommendation 160 should be implemented, but the basis for the finding that it was not implemented was not set out. The death of the 17 year old at Sir David Longlands Prison outside Brisbane (34QLD) also caused the Coroner to recommend that certified training in resuscitation and first aid be given to prison officers. In the case of the woman who died in Brisbane Watch-house (38QLD) the investigator noted that there was no guarantee that an officer trained in first aid would be on duty on any given shift. He also noted that training was dependent on the independent initiative of the police officers, and recommended compulsory pre-service and in-service first aid courses. First aid training was not raised as an issue in the case of the man who died in Bendigo Police Station (31VIC), but on the facts trained police should have attempted resuscitation, as the deceased had been seen alive not long before.

Prison officers were unable to perform resuscitation in the case of the death of a 19 year old man from epilepsy at Long Bay Gaol in 1990 (19NSW). Police who were involved in the circumstances of death of the man on the south coast of New South Wales in 1995 (76NSW) were not trained in resuscitation techniques.

After investigating the death of a man at Port Headland Lockup (2WA) very briefly, and finding that resuscitation was not attempted, the Coroner did not address the adequacy of the officers' first aid training. Lack of training may have contributed to a delay in attempting resuscitation in the case of the man who died in the East Perth Lockup (65WA).

Recommendation 161 - Custodians to Seek Medical Attention if Detainee is in Distress
That police and prison officers should be instructed to immediately seek medical attention if any doubt arises as to a detainee's condition.

All States have stated that they have implemented this recommendation. The cases indicate that this basic, commonsense message of the Royal Commission has not been communicated to operational police and prison officers. This is a cause for serious concern.

If Coroners were accurate in identifying failure to seek prompt medical attention for prisoners in distress, the worst offending state was Queensland, where five of the nine resulting deaths occurred. The woman who died in Brisbane Police Lockup (38QLD) should have been given immediate medical attention. She had been taken by police from a private home while semi-conscious and incapable of talking spontaneously. In another case an unconscious man, who had been beaten so severely that fatal head injuries were inflicted, was taken to a watch-house on Mornington Island (21QLD) instead of a medical facility. The community police who arrested the deceased had no authority to arrest, and were not trained adequately to discharge their duty of care. The fact of his unconsciousness alone should have led to the deceased being given medical attention.

The death of a man in the Rockhampton Police Watch-house eight months later involved a serious breach of this recommendation (25QLD). The watch-house staff knew that the deceased suffered from alcoholism and epilepsy. He had a noticeable facial injury. Police claimed he had refused medical attention. The Coroner found a doctor should have been called automatically in the circumstances. The Coroner commented that the deceased had been sick in the cell. By the time the inexperienced prison officers called medical attention, rigor mortis had set in.

In the case of the eighteen year old who was arrested in a park in Brisbane (53QLD), the Criminal Justice Commissioner found that the impaired consciousness of the deceased before he was handcuffed and placed in a police van was due to solely to drunkenness, not the heart condition which the post mortem report found had killed him. The deceased had vomited and urinated in his pants while lying on the ground. Police did not carefully examine his condition, but left him in the back of the police van for some twenty minutes. The lack of an examination meant that, in the words of the recommendation 'doubts as to the condition of the detainee,' did not arise.

The 17 year old who was found to have hanged himself at Sir David Longlands Prison (34QLD) should have been placed under intensive medical and psychiatric supervision. The boy's mother was very concerned about the drugs he was receiving in prison and he had apparently failed to recognise her during a recent visit, his face swollen and puffy.

The Coroner found that the evidence supported the inevitable conclusion that the deceased was a suicide risk, but that no extra procedures were put in place. He was not referred to a psychiatrist despite cutting the tendons in both wrists two weeks earlier.

The death from cancer of a man from Cooma Prison (44NSW) involved a comment by the Coroner that the deceased should have been immediately seen by a doctor when his condition began to deteriorate.

Serious criticisms were made in the course of the inquest into the death of a man conveyed from Mobilong Prison to hospital (20SA). The man had complained of chest pains for over a month, but when taken to hospital initially was treated for gastric upset. He coughed up blood after a game of football, but did not get to hospital until four hours after he notified prison officers by intercom. The Coroner found that the cumulative effect of a number of factors contributed to the death, which disclosed delay and failure to accord the deceased's health and welfare the care and attention to be expected. Due to avoidable lack of information, confused communications, misinterpretation of instructions and lack of reasonable expedition, there was an absence of adequate and prompt attention to routine procedures which the needs of a person with an accelerating deterioration in his health required. Allowing for excusable delays the Coroner found that the deceased was without proper medical care for three hours.

The woman who died at Mulawa Prison (62NSW) was another case which involved a serious failure to provide medical attention to a prisoner in distress. Over three days prisoners told prison officers that the deceased was suffering more than just drug withdrawal, and there was some evidence that the deceased was not suffering withdrawal. The deceased was pale, not eating, had a fit and had fallen. This was brought to the nurses' attention. However, nursing staff merely took the deceased's pulse, and left the deceased in a cell by herself. Later the same day the deceased was taken to the medical annexe, but was locked in the annexe for three hours or more before she was treated. Prisoners also reported that on successive nights before her death the deceased was moaning audibly. Nurses denied hearing noises from the deceased. However, the prisoners' evidence was corroborated by a prison officer who was in the adjacent cell attending to a prisoner who had stolen methadone and overdosed.

The case of the woman who died in a police van outside Prahran Police Station (36VIC) also involved a breach of this recommendation. The police knew she had recently discharged herself from the hospital, as she was wearing a hospital band, but police took her to the police station. She was obviously disturbed. Police made an effort to contact the forensic surgeon, but primarily for mental health certification rather than treatment. Nevertheless, the deceased was held unsupervised at the station in the back of the police van.

The death of a man at Townsville Watch-house (5QLD) after he had been arrested while unconscious prompted the Coroner to recommend that medical assistance immediately be sought when persons who are known to be habitual drinkers are admitted to watch-houses.

Recommendation 162 - Minimum use of Firearms
That governments give careful consideration to laws and standing orders relating to the circumstances in which police or prison officers may discharge firearms to effect arrests or to prevent escapes or otherwise. All officers who use firearms should be trained in methods of weapons retention that minimize the risk of accidental discharge.

There have been four fatal police shootings of Aboriginal people since May 1989 (18NT, 49TAS, 54SA, 66VIC). ²⁵ Three of the four had histories of mental illness (18NT, 54SA, 66VIC) and the fourth was 16 years old. Three of the four were found to be highly intoxicated (49TAS, 54SA, 66VIC). None had firearms: one had a replica pistol (49TAS); two had knives (18NT, 54SA); and one had a tomahawk (66VIC).

The Coroners found that the shootings were justifiable in self defence. Nevertheless, their recommendations indicated the need for improvements in police procedures, especially in dealing with psychiatrically disturbed people.

The Coroner in the Victorian shooting noted that police firearms training focussed on 'the criminal element' only, and did not contemplate people with psychiatric disabilities (66VIC). Recommendations included a specialist team to deal with crises involving mentally ill persons, a record of mentally ill persons on the database used by police radio support operators, and consideration of capsicum sprays and other alternatives to firearms (also a recommendation in 54SA). The Victorian Coroner was satisfied that some of these initiatives, including training in minimum use of force, were being put in place.

The issue of a warning shot was raised in the deaths. In the Northern Territory case it was found that the traditional Aboriginal man would not have understood the meaning of a warning shot, and in hindsight negotiation strategies should have been pursued. In the South Australian case there was no warning shot and the Coroner recommended a review of this policy. It was instituted by the Mitchell Committee in 1974 at a time when operational police did not generally carry guns, and when capsicum spray and other alternatives were not available. In the Victorian case a shot fired into the garden behind the deceased was somewhat questionably found by the Coroner to be a warning shot. The issue did not arise in the Tasmanian death.

In none of the cases did the Coroner specifically recommend better training in techniques to pacify and negotiate with disturbed people, although the Coroner commented that changes subsequent to the Victorian shooting included this training (66VIC). While acknowledging the difficulties which police face, the pattern of fatal police shootings of mentally ill persons is extremely disturbing. The number of fatal shootings indicate that police training should place far more emphasis on mediation/ negotiation/management techniques to calm rather than inflame aggressive situations where possible. The Northern Territory shooting involved a traditional community on Elcho Island, and the community felt that the deceased should have been left alone until his episode passed (18NT). Negotiation was not attempted and Aboriginal Police Aides who knew the deceased and spoke his Aboriginal language were kept at the rear of the party searching for the deceased.

Recommendation 163 - Restraint Training, Restraint Equipment to be a Last Resort
That police and prison officers should receive regular training in restraint techniques, including the application of restraint equipment. The Commission further recommends that the training of prison and police officers in the use of restraint techniques should be complemented with training which positively discourages the use of physical restraint methods except in circumstances where the use of force is unavoidable. Restraint aids should only be used as a last resort.

In the case of the 18 year old young man who died in Brisbane Watch-house (53QLD) police used handcuffs even though the deceased was not fully conscious. The handcuffs were not removed for approximately half an hour. Police training material tendered before the hearings indicates that officers are instructed that 'wherever and whenever possible a prisoner should be handcuffed with his hands behind his back and handcuffs are not to be removed from a prisoner other than at a place of safety (watch-house, police station, prison etc).' This training material was held to excuse the police, but its terms represent a clear breach of this recommendation, which the Queensland Government claimed was implemented.

In the case of the man who died in police custody in Adelaide (29SA) police handcuffed a man who had two artificial legs after a 15 minute struggle. The Coroner made a recommendation which implicitly criticised the exercise of the power to arrest, and the handcuffing in proportionality to the charge of offensive language, resisting arrest and assaulting police. Police statements indicated that pressure had been applied to the deceased's back while he was lying face down on the ground, and that he was unresponsive and pulseless shortly after being handcuffed.

Restraint techniques arose in the case of a man who was shot by police in Adelaide (54SA). At one point before the shooting the deceased dropped his knife. It was argued at the inquest that the dropping of the knife indicated that the deceased may well have calmed down, but an officer tried to grab him through the window of a police car. This allegedly inflamed the situation. The attempt to forcibly detain the deceased was mildly criticised, and training in restraint methods was recommended. In hindsight a policy of calm appeasement would have been more appropriate.

Possibly the most alarming breach of this recommendation occurred when police were called by an inexperienced doctor to remove an Aboriginal man from the emergency room at the Gippsland Base Hospital (8VIC). The deceased's consciousness was highly impaired. He had experienced an epileptic seizure. He had caused a disturbance by acting irrationally before police arrived, so he was handcuffed while lying on the floor, clenching and unclenching his fist.

Recommendation 164 - No Charges to be Laid for Incidents of Self-Harm
The Commission has noted that research has revealed that in a significant number of cases detainees or prisoners who had inflicted self-harm were subsequently charged with an offence arising from the incident. The Commission recommends that great care be exercised in laying any charges arising out of incidents of attempted self-harm and further recommends that no such charges be laid, at all, where  self-harm actually results from the action of the prisoner or detainee (subject to a possible exception where there is clear evidence that the harm was occasioned for the purpose of gaining some secondary advantage).

Charges for self-harm were laid in one case. The deceased in the case of the man who died at Rockhampton Prison in 1991 (14QLD) received a three month sentence three days prior to his death for damaging government property in a suicide attempt. He had been arrested for drunkenness, and knotted strips of blanket were discovered during a check of his police cell. The Longreach District Officer submitted a report to Rockhampton Correctional Centre following this incident stating that [the deceased] was a potential suicide risk. Extraordinarily, the local court referred the matter to the district court as it regarded the offence as a serious one. A Townsville Aboriginal lawyer claimed that police at the Townsville and Palm Island watch-houses laid two charges of damage against suicidal Aborigines in a seven month period. ²⁶

The issue arose in Western Australia recently. The Chief Justice of the District Court imposed a three month sentence for criminal damage on a 21 year old Aboriginal prisoner who set fire to his mattress and inhaled a dangerous amount of smoke. ²⁷Immediately before setting fire to his cell he had been suffering a chronic migraine. When he called for help on the intercom he was told that he had missed the medical parade, so he would not be given medication. The prison officer disconnected the intercom. He had already been punished by two months segregation.

Recommendation 165 - Minimisation of Potential Dangers in Cells
The Commission notes that prisons and police stations may contain equipment which is essential for the provision of services within the institution but which may also be capable, if misused, of causing harm or self-harm to a prisoner or detainee. The Commission notes that in one case death resulted from the inhalation of fumes from a fire extinguisher. Whilst recognizing the difficulties of eliminating all such items which may be potentially dangerous the Commission recommends that Police and Corrective Services authorities should carefully scrutinize equipment and facilities provided at institutions with a view to eliminating and/or reducing the potential for harm. Similarly, steps should be taken to screen hanging points in police and prison cells.

The recommendation that hanging points be removed is the most significant part of this recommendation.

A Coroner made the point in the case of the man who hanged himself with a television cable in Pentridge Prison (47VIC) that the screening of hanging points, and the removal of the means of self harm, should not be taken to an extreme. This observation is an astute one. However, if a prisoner has exhibited behaviour which indicates that he is at risk, the intelligent removal of hanging points should be one feature of protocols required under Recommendations 127f(iii) and 152g(iii). Even so, removing hanging points should not mean forced inactivity in a cell that is totally barren and sterile.

In the extreme case, a prisoner in segregation who is mentally ill, who has recently attempted suicide and who is at risk of suicide should not have the means to kill himself in an isolation cell. Unfortunately, those were the facts in the death of a man suffering from paranoid schizophrenia in Townsville Prison in 1992 (43QLD). He was placed in an observation cell after lighting a fire and barricading himself in his cell, and telling prison officers that he was hearing voices and wanted to see a doctor. A nurse placed him on 'strict observation,' and the visiting government medical officer advised her by telephone to sedate the prisoner nightly. However, the bars provided a hanging point and an old mattress cover was easily torn to provided a ligature. Conditions in the cell were described as appalling.

Mental illness featured in five of the deaths in which hanging points had not been removed. The man who hanged himself in Port Augusta Prison (73SA) had been transferred from a mental health institution to the prison ten days prior to his death. A belt, a commonly used instrument for hanging, was left in the deceased's possession. He was found hanged in his cell with the belt attached to a hole in the mesh above the cell door. Prison officers did not hear the noise made when that the deceased had knocked a hole, large enough to thread the belt through, through the steel mesh door. The noise was heard by several other Aboriginal prisoners, and the deceased told one of those prisoners the next day that he had made the hole in order to hang himself. Unfortunately the prisoner failed to pass this information on.

The death in an adult prison, Sir David Longlands Prison in Brisbane, of a juvenile with mental health problems (34QLD) was another case in which there were warning signs and hanging points should have been removed. About a week before he died the deceased cut both his wrists after a disagreement with his girlfriend. He was returned to his cell after 24 hour observation. A few days later he was locked in his cell for 48 hours, during which time he destroyed his cell. A doctor prescribed medication for his 'acutely disturbed' state. A day later he was moved from the youthful offender unit into the mainstream adult prison. His body was found the next day hanging by a bed sheet suspended from the cell bar of the window above the cell door.

A prisoner suffering from schizophrenia who died at the Arthur Gorrie Remand Centre had been recently institutionalised (59QLD). Records showed that he had made suicide attempts and had been the subject of a suicide watch during a period of incarceration at the Correctional Centre six months previously. The nurse did not read his file when it became available. The deceased was found hanging in his cell by a sheet tied to the bars of his cell door.

At Yatala Labour Prison in South Australia plumbing on the roof of the cells provided an obvious hanging point, and recommendations for the covering of the pipes following deaths by hanging were not followed up in time to prevent a further Aboriginal death (60SA, 68SA), as well as a non-Aboriginal death. The Coroner recommended at the first inquest that the Department of Corrective Services urgently reconsider its policy of reliance on detection of 'at risk' prisoners and instigate refurbishment of B Division cells to minimise potential hanging points. When an 18 year old prisoner later hanged himself from the exposed pipes, prison officials advised that cost and the problem of making the cells even more claustrophobic with a false ceiling was the basis of their decision not to follow the earlier recommendation. At the second inquest the Department stated that work was underway to cover the pipes in cells used as emergency accommodation for 'at risk' prisoners. In the case of the death of a man who died in Borallon Prison in Brisbane in 1994 (74QLD) the Coroner recommended that anchor points should be covered in some way to prevent ties being made to them. The Coroner had made a similar recommendation in relation to a death in custody in Rockhampton in 1988.

In the case of the man who died in the police lockup in Ceduna (1SA), the deceased threaded his shoelaces through a mesh grill that had, ironically, been installed to prevent the use of bars as hanging points. A woman who was a sentenced prisoner died in Macquarie Fields Police Station (39NSW) in a cell with hanging points which was not appropriate for the holding of prisoners overnight.

The man who died at Geraldton Regional Prison (33WA) had recently been hospitalised for an overdose, a factor not discussed in any detail by the Coroner. This should have alerted authorities to the need to avoid placing him in a cell where there were he could use the cell cross bar to hang himself.

In the case of the man who died at Bendigo Police Station (31VIC) the police did not believe that the deceased was Aboriginal, and did not remove his shoelaces. Another Aboriginal prisoner in the cells that night had his shoelaces removed. The deceased was intoxicated at the time of his arrest, which is a risk factor.

In Queensland there was a high number of hangings where prisoners at risk were placed in cells with hanging points. Two men who died on consecutive days in Rockhampton Correctional Centre (13QLD, 14QLD) were both alone in cells with hanging points despite displaying behaviour which indicated they were at risk. In the first case one end of a piece of a sheet was knotted around his neck with the other end fastened to a mesh grill at the front of the cell. In the second death the deceased, whose file was marked suicidal, was hanging suspended from a piece of white material attached to the lower centre louvre at the rear of cell. He had also cut his wrists, indicating that he must have had a sharp object with him in his cell.

A 21 year old unsentenced prisoner died in similarly tragic circumstances (45QLD). He had been moved from the Brisbane Watch-house as a suicide risk on the day of his arrest, and was given unspecified medication on reception at Arthur Gorrie Remand Centre because he was a suicide risk. He was reclassified as not at risk two days later, on the day of the suicide. It seems he was placed in a cell by himself. The deceased hung himself with prison socks issued to him on the afternoon of his death.

A man who died in Townsville Prison in 1994 (64Qld) was found hanging from a ventilation grill by a piece of bed sheet material which was tied around his neck. An Indigenous woman appointed as an investigator indicated that prison documents showed him to be a high suicide risk prisoner. She also expressed concern at the segregation cells at the Townsville Correctional Centre, describing them as filthy, dingy and with inadequate sanitation facilities.

It is clear that obvious hanging points, such as cell bars and plumbing, should be covered in a manner to prevent self-harm in cells. Equally, items such as belts and shoe laces should be taken from people who are 'at risk.' However, the exhaustive endeavour to remove all potential means of self-harm in a cell is a fruitless exercise. The very bareness and total lack of amenity is as likely to provoke the desire to attempt suicide. Sensible precautions must be taken, but the deeper lesson is that the reduction of self-harm and suicide is ultimately not about hardware, It is a question of humane and responsive treatment. A high level of human interaction and vigilance are essential to minimise the desire and the performance of self-injury.

The chalkboard project at Murgon Watch-house is another example of a means of reducing the oppressive nature of cells with hanging points removed.

Recommendation 166 - Exchange of Information Between Police and Corrective Services
That machinery should be put in place for the exchange, between Police and Corrective Services authorities, of information relating to the care of prisoners.

See discussion under recommendation 130 on protocols for exchange of information regarding physical or mental condition of people in custody. It is commendable that the police did notify prison authorities of suicide risk in a number of cases. In the case of the man who died in Townsville Prison in 1990 the government medical officer who saw the deceased while he was in police custody informed the police of his depression, and his file was marked suicidal.

The death of the 19 year old in the Arthur Gorrie Remand Centre in Queensland (59QLD) primarily involved a failure to transfer information from the psychiatric institution where the deceased had been incarcerated. However, the information as to the deceased's medication and condition were known to police, and this information should have been conveyed to the prison authorities.

There was controversy over whether the man who died in Townsville Prison in 1994 (64QLD) was classified by the prison as being at risk of suicide. Prison authorities denied they had been informed by the Gurrindal Cell Visitors Program that the deceased had made suicide threats while at the Townsville Watch-house. Under this recommendation, the police should presumably have liaised with the cell visitors and conveyed this information to the prison authorities.

In the case of the man from Silverwater Prison who died of encephalitis (7NSW), the deceased's mother informed a police officer of the deceased's complaint of an ear-ache, which turned out to be a symptom of the fatal condition.

In the case of the 19 year old who died in Parklea Prison (67NSW) police had completed an at risk form, which was marked suicidal. Screening forms were then completed at Parklea Prison, but the deceased classified poorly, and proper procedures were not adopted. The form used a system of 'high risk points.' The box marked 'first time in custody' was not ticked, on the basis that the deceased had spent time in juvenile justice institutions. It was his first time in prison. The deceased had attempted suicide as a 13 year old and as a 15 year old.

5. Prison Experience

Coronial inquests into deaths in prisons occasionally provide information on general custodial conditions. The cases show a wide variation in conditions across prisons. In one respect there is uniformity: certain recommendations have not been implemented in any prisons. Table 8.5 indicates that a significant number of breaches concerned shared custodial accommodation (R173), Aboriginal Welfare Officers (R174), transition period for new prisoners (R175) and segregation (R181). The majority of the breaches occurred in the second period (25 March 1992 - 13 January 1996). This probably reflects the increased scope of coronial investigations. The breaches occur in States which have had a significant number of prison deaths. The case profiles indicate that prisons in Queensland fall significantly below the standards of other prisons.

Table 8.5 Prison Experience

View the table

Recommendation 168 - Distance From Family
That Corrective Services effect the placement and transfer of Aboriginal prisoners according to the principle that, where possible, an Aboriginal prisoner should be placed in an institution close as possible  to the place of residence of his or her family. Where an Aboriginal prisoner is subject to transfer to an institution further away from his or her family the prisoner should be given the right to appeal that decision.

Queensland and Western Australia claim full implementation of this recommendation while Victoria concedes that this recommendation has not been implemented.

Distance from family was raised in three case in Queensland. In the case of the man who died at Lotus Glen Prison (near Cairns) (22QLD), the deceased was 350 kilometres from his family at Palm Island (near Townsville). The deceased's last visit from his family was five months before his death. A newspaper paid for the deceased's mother to visit. It is unclear why the deceased was not incarcerated in a juvenile facility or Townsville Prison. It may have been because Townsville Prison could not care for a prisoner with AIDS, with sections described as unfit for human habitation (see 43QLD). The Coroner found that the deceased's isolation was a contributing factor in his death.

In the case of the man who died at Townsville Prison (43QLD) the deceased was to be transferred from Lotus Glen Prison to Rockhampton Prison to be near his only 'blood relative'. However, he was kept at Townsville Prison in transit from 22 October 1992. In early November the deceased was charged with assault and brought before Townsville Local Court. The case was subsequently delayed as the deceased was not making sense to his solicitor. After six weeks at Townsville Prison he hanged himself. The Coroner heavily criticised the decision of authorities to keep the deceased at Townsville Prison in transit when the purpose was to transfer him to Rockhampton to be near his sister.

In another case the Coroner criticised the refusal by prison authorities to allow a visit by the immediate family of a prisoner who was moved from the Brisbane Watch-house on the basis that he was a suicide risk (45QLD). The recommendation takes for granted the right of access to prisoners by the immediate family of the deceased. The importance of family visits to remand prisoners adjusting to their imprisonment cannot be overemphasised, especially when the remandee is suicidal. It is perverse to deny a suicidal prisoner contact with his family.

Recommendation 169 - Financial Assistance For Family
That where it is found to be impossible to place a prisoner in the prison nearest to his or her family sympathetic consideration should be given to providing financial assistance to the family, to visit the prisoner from time to time.

This recommendation is claimed to have been implemented in three states (Queensland, Victoria and Western Australia) and partially implemented in three other states (New South Wales, South Australia and Tasmania). The Northern Territory does not support this recommendation.

The necessity for funding for families to visit is demonstrated by the case of the man who died at Lotus Glen (22QLD). (see discussion under recommendation 168.) A newspaper paid for the only visit by the deceased's mother. The Coroner found the deceased's isolation was a contributing factor in his death and recommended that funding and transport be available for family visits and that families be assisted in these arrangements by Aboriginal support groups.

The failure of the Northern Territory Government to even support this recommendation is alarming. In a recent case prison officials refused a request for extra telephone calls, to be paid for by the family reverse charge, by an Aboriginal man from New South Wales on remand in the Northern Territory. He was told that prison policy allowed one phone call per month that is to last no more than five minutes. Petitions by various organisations on his behalf, including this Office, were refused. The closure of Gunn Point Prison in the north and the construction of a new prison in Alice Springs will result Top End prisoners, unable to be held in Berrimah Prison, being over 1500 kilometres from their families. This will create an insuperable barrier to many families.

Recommendation 170 - Facilities For Visitors
That all correctional institutions should have adequate facilities for the conduct of visits by friends and family. Such facilities should enable prisoners to enjoy visits in relative privacy and should provide facilities for children that enable relatively normal family interaction to occur. The intervention of correctional officers in the conduct of such visits should be minimal, although these visits should be subject to adequate security arrangements.

Four jurisdictions claim implementation of this recommendation (Victoria, Queensland, Western Australia and Northern Territory). The remaining jurisdictions claim part implementation.

The most inhumane breach of this recommendation concerned not facilities for visits, but prison rules placing indefensible limits on access to a suicidal remand prisoner. A request by the immediate family to visit the man who died in Arthur Gorrie Remand Centre in 1993 (45QLD) was denied. The deceased had been moved from the Brisbane watch-house on the day of his arrest on the basis that he was a suicide risk. The prison rules allowed only week-end visits.

Recommendation 171 - Special Family Occasions
That Corrective Services give recognition to the special kinship and family obligations of Aboriginal prisoners which extend beyond the immediate family and give favourable consideration to requests for permission to attend funeral services and burials and other occasions of very special family significance.

All jurisdictions claim implementation of this recommendation. There was no information from the case profiles on attendance at funerals or very special family occasions. However, the New South Wales Department of Corrective Services is to be commended for its support for attendance by prisoners at funerals of family members.

Recommendation 172 - Visits From Legal Services
That Aboriginal prisoners should be entitled to receive periodic visits from representatives of Aboriginal organisations, including Aboriginal Legal Services

All jurisdictions claim implementation of this jurisdiction. Visitations from the ALS was only raised in one case. In the case of the man who died at Arthur Gorrie Remand Centre (59QLD) the mother of the deceased stated that the ALS field officer had not returned her call regarding help for her son. The Queensland ALS stated earlier this year that resources were insufficient. The lack of funding for Aboriginal Legal Services is discussed extensively in chapter 12. Within reasonable restraints imposed by funding it is axiomatic that all ALS prioritise attendance where a person in custody is considered particularly at risk.

Many of the cases indicate that this task is being fulfilled by Deaths in Custody Watch Committees. This is a welcome development, but co-ordination with Legal Services will still be necessary when legal issues as to prisoners welfare and health arise.

Recommendation 173 - Humane Environment
That initiatives directed towards directed to providing a more humane environment through introducing shared accommodation facilities for community living, and other means should be supported, and  pursued in accordance with experience and subject to security requirements.

All jurisdictions claimed full implementation of this recommendation except Western Australia and South Australia who claim part implementation.

In many cases the deceased were not housed in shared cells. This was occasionally the result of the deceased's request (see 27NSW and 51NSW). It was generally unclear as to whether shared cell accommodation was available. See for example cases involving suicide in:

• Queensland (13QLD, 14QLD, 22QLD, 34QLD, 43QLD, 59QLD and 74QLD);
• South Australia (60SA, 68SA and 84SA); and
• Western Australia (33WA).

In the cases of a 17 year old juvenile at Sir David Longlands Prison (34QLD) and a 22 year old man at Yatala Labour Prison (82SA) the deceased both had cell mates.

The recommendation was listed as breached in four cases. In the case of the man who died in Lithgow Prison (26NSW) the Coroner criticised the prison for not having two-out cells. The prison only had buddy cells: two cells joined by a door.

It was clear that cells could not be described as humane in the case of the juvenile who died at Maitland Prison (6NSW) and two deaths at Townsville Prison (43QLD, 64QLD). In the former death the Coroner criticised the prison for placing the deceased in a cell without a light switch or buzzer. In the latter deaths the prison was described by Aboriginal organisations and the Human Rights Commission as unfit for human habitation.

Recommendation 174 - Aboriginal Welfare Officers
That all Corrective Services authorities employ Aboriginal Welfare Officers to assist Aboriginal prisoners, not only with respect to any problems that they might be experiencing inside the institution but also in respect of welfare matters extending outside the institution, and that such an officer be located at or frequently visit each institution with a significant Aboriginal population.

Corrective Services in New South Wales and Victoria claim full implementation of this recommendation and other States and Territories claim part implementation. However, very few prisons have Aboriginal Welfare Officers.

In New South Wales coroners have criticised Corrective Services for failing to employ Aboriginal Welfare Officers (67NSW, 72NSW). The coroners found that an Aboriginal Welfare Officer could have respectively assisted the deceased in obtaining bail and adjusting to prison life.

The position of the New South Wales Government in 1994 was that there were seven designated positions. ²⁸ The Minister for Corrective Services in early 1996, in response to coronial recommendations in the case at Parklea Prison (67NSW), stated that seven positions exist but they were yet to be advertised.

The positions in New South Wales were in fact created before the Royal Commission. They were rarely filled, however, and when they were filled they were often filled by non-Aboriginal people. The Government claimed the recommendation had been implemented in 1992. In 1993 it noted that the position to exclusively serve Aboriginal inmates at the Long Bay Prison had been deleted. The 1994 response revealed that there was still no-one in the Long Bay position, as 'applicants lacked experience.' Yet an Aboriginal applicant for a positions at the Aboriginal Resource centre, with solid references and a recommendation from an interview panel, had his appointment vetoed because he had a criminal record. The failure to advertise the Aboriginal Welfare Officer positions is reprehensible in light of the continued misleading repetition of the fact that there were seven designated Aboriginal Welfare Officer 'positions,' as opposed to appointments made, and that these were often not filled or not filled by Aboriginal people.

It is often indicated that there are not suitably qualified people available. If this is the case prisons should review their criteria. Lack of formal qualification should not be a bar to employment. The Royal Commission states in recommendation 238:

In making appointment of trainers preference should be given to Aboriginal people with a proven record of being able to relate to, and influence, young people even though such candidates may not have academic qualifications.

Furthermore, a criminal record should not be an automatic bar to employment.2 As the case of a 24 year old man who died at Long Bay Prison (63NSW) revealed, an Aboriginal sweeper (inmate) was filling the role of Aboriginal Welfare Officer, particularly in caring for new inmates. A paid, qualified employee should fill this role. The New South Wales Department of Corrective Services refused to employ an applicant recommended for employment in the Aboriginal Resource Unit on the grounds of his criminal history.

The absence of Aboriginal Welfare Officers is evident in cases in other jurisdictions. It appears that there was no Aboriginal Welfare officer at Rockhampton prison in 1990 when a 21 year old man and a 24 year old man hanged themselves on successive evenings (13QLD, 14QLD). The Queensland Corrective Services Commission internal report into the death at the Townsville Prison in 1992 (43QLD) revealed that there was no Aboriginal Welfare Officer at the prison. In the case of the 21 year old man who died at Arthur Gorrie Remand Centre (45QLD) the Coroner recommended that Aboriginal Counsellors be available as part of the risk assessment team.

In the case of the 30 year old man who died at Canning Vale Prison (56WA) the ALS submitted that the Prison should introduce Aboriginal Welfare Officers to assist prisoners to enable contact with family and culturally appropriately care.

After the death of another Aboriginal remand prisoner in April 1996 (96WA) the government announced it would be introducing Aboriginal Peer Support Officers in Western Australian prisons. There has been an Aboriginal Peer Support Officer in Geraldton prison for some time.

In the case of a 22 year old who died at Yatala Labour Prison on 17 March 1994 (60SA) the deceased's Aboriginality was not noted by prison authorities but was known by other Aboriginal inmates. The deceased later committed suicide. The State Coroner noted that inmates did not trust the few social workers who were available. If an Aboriginal Welfare Officer was employed at the prison some of these problems may have been averted.

An Aboriginal Welfare Officer was employed at the prison soon after the death. Regrettably, the unofficial code of silence put the officer in an invidious position when the next death occurred on 27 January 1995. The officer had received certain information about the deceased's suicidal ideation, but did not pass it on to authorities. Of course, unnecessarily oppressive conditions in safe cells, such as forced inactivity and boredom, may perpetuate this code of silence. If this is the case, and an Aboriginal Welfare Officer feels that a suicidal prisoner's distress will only increase as a result of placement in a safe cell, the officer may feel compelled not to report. See the discussion under Recommendation 152f on the code of silence.

The employment of Aboriginal Welfare Officers is essential in allowing the proper implementation of many of the recommendations, particularly those relating to mental health and welfare. Aboriginal Welfare Officers are crucial in the initial period of imprisonment and should be intimately involved with new inmates in the transition period discussed below in recommendation 175. It is significant that the cases discussed above all occurred in the second of the two periods covered in this report, 25 March 1992 -13 January 1996.

Recommendation 175 - Transition Period
That consideration be given to the principle involved in the submission made by the Western Australian Prison Officers' Union that there be a short transition period in a custodial setting for prisoners prior to them entering prison routine.

Transition to prison life is difficult. Australian and overseas research has shown that prisoners are extremely vulnerable to self harm and suicide in the initial stages of their incarceration. ²⁹ In 1993-4 the proportion of deaths among remand prisoners (Indigenous and non-Indigenous) was more than three and a half times their proportion in the prison population. ³⁰ The death of the man in the Canning Vale Remand Centre in April 1996 was the seventh death of a remand prisoner in Western Australia in 18 months.

The Royal Commission interpreted the submission of the Western Australian Prison Officer's Union as allowing remandees and freshly sentenced prisoners to be held in holding cells. They would have access to telephones to talk with their family to ease emotional trauma and make arrangements for their children and other matters. This would also facilitate the making of bail applications. A transition period is particularly critical for inmates prone to self-destructive behaviour.

This recommendation has been interpreted differently by State Governments. Implementation reports refer to induction programmes where prisoners are familiarised with the prison. All jurisdictions claim full implementation except South Australia and Northern Territory. Despite this interpretation and implementation claims the reports actually indicate that induction programmes operate in very few prisons. Some mention is made of a programme in New South Wales at the John Moroney prison, but the Government's response actually confuses a induction programme with screening assessment. ³¹ It is encouraging that a remand transition program is being piloted at the Adelaide Remand Centre 'where new inmates are eased into the prison system.' ³² Despite tabloid newspaper accounts, prison is a brutal environment.

A number of these deaths indicate that a transition period, in conjunction with the employment of Aboriginal Welfare Officers (recommendation 174) may have prevented the death of prisoners who were not coping with prison life (see 72NSW and 45QLD). A transition period could also have assisted the deceased obtain bail in the case of the 19 year old man who died at Parklea Prison (67NSW). The deceased had been granted bail but had difficulty in properly communicating with his family to obtain the money. If there had been a more flexible custodial setting this may have been possible.

Recommendation 176 - Complaints Officer
That consideration should be given to the establishment in respect of each prison within a State or Territory of a Complaints Officer whose function is:

a. To attend at the prison at regular (perhaps weekly) intervals or on special request for the purpose of receiving from any prisoner any complaint concerning any matter internal to the institution ; which complaint shall be lodged in person by the complainant;

b. To take such action as the officer thinks appropriate in the circumstances;

c. To require any person to make enquiries and to report to the officer;

d. To attempt to settle the complaint;

e. To reach a finding (if possible) on the substance of the complaint and to recommend what action if  any, should be taken arising out of the complaint; and

f. To report to the complainant, the senior officer of the prison and the appointing Minster (see below)  the terms of the complaint; the action taken and the findings made.

g. This person should be appointed by, be responsible to and report to the Ombudsman,  Attorney-General or Minister for Justice. Complaints receivable by this person should include, without in any way limiting the scope of complaints, a complaint from an earlier complainant that he or she suffered some disadvantage as a consequence of such earlier complaint.

All jurisdictions claim full implementation except South Australia which claims part implementation.

The case of the man who died in Canning Vale Prison in 1991 illustrates the need for an independent complaints system in prisons, and one which takes in health care complaints (23WA). The deceased died from a heart attack after having complained of chest pains, over a period of weeks, to many witnesses who gave evidence at the inquest. The Coroner found that the deceased had not informed the prison doctor of his complaint, despite the evidence of other prisoners who were in the waiting room with the deceased, that he had complained to them. He certainly had no faith in the prison medical service. The deceased was in the process of attempting to organise a visit by a doctor independent of the prison medical service when he died. Where a prison medical employee takes the view that a serious condition is not serious, there is no alternative source of medical assistance a distressed inmate can turn to. An adequately accessible complaints mechanism following the model of this recommendation is a necessary remedy to this problem. Such a system would have been invaluable in circumstances of the 1994 death of a woman in Mulawa prison (62NSW).

The Royal Commission found that complaints by Aboriginal people about prison life are relatively infrequent, attributable to a sense of powerlessness and a cultural reluctance to complain to non-Aboriginal authorities. The Royal Commission noted in making this recommendation that Aboriginal visitors schemes have inadequate input into administrative procedures. This dampens their effectiveness in enhancing accountability and problem identification in prisons and corrections health services. Given literacy levels amongst inmates complaints systems should be as informal and accessible as possible, but at the same time responsive and carefully documented. Prisoners should be able to contact Aboriginal prison visitors by telephone rather than having to wait for visits in cases such as this. (See also recommendation 179)

Recommendation 177 - Racism and Cross-Cultural Education
That appropriate screening procedures should be implemented to ensure that potential officers who will have contact with Aboriginal people in their duties are not recruited or retained by police and prison departments whilst holding racist views which cannot be eliminated by training or re-training programs.  In addition, Corrective Service authorities should ensure that all correctional officers receive cross-cultural education and an understanding of Aboriginal-non-Aboriginal relations in the past and the  present. Where possible, that aspect of training should be conducted by Aboriginal people (including Aboriginal ex-prisoners). Such training should be aimed at enhancing the correctional officers' skills in cross-cultural communication with and relating to Aboriginal prisoners.

All jurisdiction claim part implementation except Victoria and Northern Territory who claim full implementation. For cross-cultural health training see recommendation 154 and 155. There was no information on racism by officers and non-health cross-cultural education presented by the case profiles.

Recommendation 178 - Employment of Aboriginal Staff
That Corrective Services make efforts to recruit Aboriginal staff not only as correctional officers but to all employment classifications within Corrective Services.

All jurisdictions claim partial implementation, except New South Wales and Northern Territory who claim full implementation.

However, Coroner Abernathy criticised both New South Wales Corrective Services and Police Services for failing to employ Aboriginal people (63NSW). The NSW Department claimed it was proceeding to a target of 2% Aboriginal employment. Follow up revealed that most of those on record as being Aboriginal had never claimed to be Aboriginal, and a more accurate figure was 0.4%. ³³

In New South Wales uniformed staff have recently been put into the Corrective Services Aboriginal Resources Unit, deterring prisoners from attending it. A prison officer who prisoners claim has a history of seriously mistreating inmates recently declared himself Aboriginal and was appointed to a position within the Aboriginal Resource Unit, although he is apparently not accepted as Aboriginal by the Aboriginal community, and his working there has been resented by inmates. In at least one case an Aboriginal person who successfully completed an interview process was refused employment on the basis of his criminal history. See also recommendation 174.

Recommendation 179 - Complaints
That procedures whereby a prisoner appears before an officer for the purpose of making a request,  or for the purpose of taking up any matter which can be appropriately taken up by the prisoner before that officer, should be made as a simple as possible and that the necessary arrangements should be made  as quickly as possible under the circumstances.

All jurisdictions claim implementation of this recommendation. Two cases raised issue of complaints. The deceased was being transferred from Lotus Glen Prison to Rockhampton Prison to be closer to his sister in the case of the 27 year old man who died at Townsville Prison (43QLD). He was held in transit at Townsville Prison. The deceased complained to the prison counsellor about the delayed transfer and also asked for paints so he could continue his traditional painting. ³⁴ Neither the complaint nor the request were acted upon. The Coroner found that this 'prolonged stopover was the catalyst that proved too much' and led the deceased to commit suicide. If a proper complaints system had been in operation then the deceased may have been quickly taken to Rockhampton as was originally intended.

The other case was the woman who died at Mulewa prison in 1994 (62NSW). The Coroner found that her obvious need for medical attention was disregarded by medical staff. She only received treatment when other prisoners disobeyed prison rules in protest at her treatment.

Recommendation 180 - Prison Offences
That where a prisoner is charged with an offence which will be dealt with by a visiting Justice, that Justice should be a Magistrate. A charge involving the possibility of affecting the period of imprisonment should always be dealt with in this way. All charges of offences against the general law should be heard in public courts.

Western Australia and South Australia only claim part implementation as they continue to use Justices of Peace to hear charges concerning offences by prisoners. (See discussion on recommendation 98 in chapter 7.)

In the cases of the 24 year old man who died at Rockhampton Prison (14QLD) and the 27 year old man who died at Townsville Prison (43QLD) the deceased were charged for prison offences (destroying prison property and assault). In both cases the offence was heard by a Magistrate at the Local Court. In the former cases the matter was removed to the District Court. The 21 year old man who died at Rockhampton Prison on 1 April 1990 (13QLD) had committed 20 summary offences against the Prison Act but there is no information as to the qualifications of the Justice he appeared before.

Recommendation 181 - Segregation
That Corrective Services should recognise that it is undesirable in the highest degree that an Aboriginal prisoner should be placed in segregation or isolated detention. In any event, Corrective Services authorities should provide certain minimum standards for segregation including fresh air, lighting, daily exercise, adequate clothing and heating, adequate food, water and sanitation facilities and some access to visitors.

All jurisdictions claim full implementation except Queensland, which only claims part implementation.

Five cases concerned Aboriginal prisoners who were isolated or segregated from other prisoners. In the case of the 17 year old juvenile who died at Lotus Glen Prison (22QLD) the deceased had the AIDs virus and was consequently placed in isolation. The conditions of the isolation were adequate and complied with the above recommendation. ³⁵ However, it is questionable whether isolation was appropriate. While prison officials informed the Coroner that other prisoners would not be disposed towards sharing a cell with the deceased, a visitor to the prison reported that inmates spoke otherwise. The Coroner found that the isolation was a contributing factor in the deceased's death.

In the case of the 17 year old juvenile who died at Sir David Longlands Prison (34QLD) there was a 48 hour lock down in the prison due to the transfer of high security prisoners shortly before the deceased's suicide. The deceased requested to be let out and, after refusal, destroyed the contents of the cell. While a general lock down may have been necessary, arrangements for prisoners to mix with others, particularly if already showing suicidal tendencies, should have been made.

An internal report into the case of the 27 year old man who died at Townsville Prison (43QLD) found that the deceased was put into a detention unit after an argument with a prison officer, which is in contravention of the Corrective Services Act (Qld).

An Aboriginal investigator in the case of the 35 year old man who died at Townsville Prison (64QLD) described the segregation cells as filthy, dingy and with inadequate sanitation facilities.

A 17 year old juvenile who died in Yatala Prison on 27 January 1995 (68SA) was placed in a maximum security cell in an adult prison. For a juvenile with a short sentence (nine months) isolation of this nature cannot be justified.

The Royal Commission's discussion of the need for human interaction and external stimuli for prisons is discussed in recommendation 152g(iv), which concerns protocols for those at risk of self-harm. The risk of suicide is intensified when prisoners are isolated and segregated. Self-harm protocols should be adopted for those so situated.

The Aboriginal Death in Custody Watch Committee claims that in most prisons Aboriginal prisoners make up a much higher proportion of prisoners in segregation cells than their proportion in the prison would suggest they should. It was acknowledged in prison regulations as early as the 1860's in New South Wales that Aboriginal prisoners have difficulty coping with segregation. ³⁶ As a result, Aboriginal prisoners in Berrima Gaol were exempted in 1862 from a regulation requiring all prisoners serving terms of five years or more from a mandatory initial term of segregation. ³⁷ The history of lack of improvement in cultural awareness has been a long one.

Recommendation 182 - Humane and Courteous Interaction
That instructions should require that, at all times, correctional officers should interact with prisoners in a manner which is both humane and courteous. Corrective Service authorities should regard it as a serious breach of discipline for an officer to speak to a prisoner in a deliberately hurtful or provocative manner.

All governments claim implementation of this recommendation. At least three cases raise issues of less than courteous and humane treatment by prison officers. In the case of the 30 year old man who died at Yatala Labour Prison (9SA) on 4 November 1989 the Coroner did not accept evidence in the submission from the next of kin alleging verbal abuse and victimisation of the deceased by some prison officers. The evidence was not admitted on the ground that it was not directly related to the death. This evidence was therefore not referred to the relevant authority.

The circumstances of the case of the woman who died in Mulawa prison in 1994 also involved a breach of this recommendation for humane interaction (62NSW). Staff disregarded the deceased's audible moaning over two days before medical attention was sought.

In the case of the 21 year old man who died at Rockhampton Prison on 1 April 1990 (13QLD) the deceased had been questioned by a prison officer regarding something that was passed to him by a fellow prisoner. The prison officer followed the deceased into the gymnasium where a heated exchange occurred. The Coroner found that the deceased approached the officer and punched him. The deceased was then restrained by prison officers and put in segregation. The psychologist had earlier formed the view that the deceased was 'hypersensitive and would react to incidents of violence'. Unfortunately this information was not communicated to prison officers which could have affected the way prison officer interacted with the deceased.

Recommendation 183 - Aboriginal Support Groups
That Corrective Services authorities should make a formal commitment to allow Aboriginal prisoners to establish and maintain Aboriginal support groups within the institution. Such Aboriginal prisoner support groups should be permitted to hold regular meetings in institutions, liaise with Aboriginal service organisations outside the institution and should receive a modest amount of administrative assistance for the production of group materials and services. Corrective service authorities should negotiate with such groups for the provision of educational and cultural services to Aboriginal prisoners and favourably consider the formal recognition of such bodies as capable of representing the interests and viewpoints of Aboriginal prisoners.

The cases provided little information on Aboriginal support groups. In the case of the 17 year old juvenile who died at Lotus Glen Prison on 12 January 1991 (22QLD) the Coroner recommended that Aboriginal support groups be established to assist in maintaining close family relationships, including funding and transport.

In New South Wales the Aboriginal Deaths in Custody Watch Committee are given formal recognition in the prisons. An active support group, the Sansbury Association, operates at Yatala Labour Prison in South Australia (see 60SA).

Recommendation 184 - Work and Education
That Corrective Services authorities ensure that all Aboriginal prisoners in all institutions have the opportunity to perform meaningful work and to undertake educational courses in self-development, skills acquisition, vocational education and training including education in Aboriginal history and culture. Where appropriate special consideration should be given to appropriate teaching methods and learning dispositions of Aboriginal prisoners.

In the case of the 24 year old man who died in the Long Bay Remand Centre (63NSW) the Coroner expressed concern that there was no remand program. He found that such a program was necessary as remandees were unsentenced, unsettled and often young.

The Coroner in the case of a 22 year old man who died at Yatala Labour Prison (60NSW) found that a contributing factor in the deceased's self-inflicted death was the lack of educational, vocational and employment training programs which was a result of staff cut backs. Similarly, in the case of the man who died at Port Augusta Prison (73SA) the ALRM has questioned the lack of work or studies available for prisoners at the prison. The ALRM suggested that this may have been a contributing factor in the deceased's suicide.

Recommendation 185 - Education Strategy
That the Department of Education, Employment and Training be responsible for the development of a comprehensive national strategy designed to improve the opportunities for the education and training of those in custody. This should be done in co-operation with state corrective Services authorities, adult education providers ( including in particular independent Aboriginal-controlled providers) and State departments of employment and education. The aim of the strategy should be to extent the aims of the Aboriginal Education Policy and the Aboriginal Employment Development policy to Aboriginal prisoners, and to develop suitable mechanisms for the delivery of education and training programs to prisoners.

There was no information on education strategies presented by the case profiles.

Recommendation 186 - Remuneration for Work
That prisoners, including Aboriginal prisoners, should receive remuneration for work performed. In order to encourage Aboriginal prisoners to overcome educational disadvantage, which most Aboriginal people presently suffer, Aboriginal prisoners who pursue education or training courses during the hours when other prisoners are involved in remunerated work should receive the same level of remuneration. (This recommendation is not intended to apply to study undertaken outside the normal hours of work of prisoners).

There was no information on remuneration for work presented by the case profiles.

6. Towards Better Health

The Royal Commission made 26 recommendations concerning Aboriginal people and the health system. While this study is concerned with the criminal justice system a number of cases involved treatment of the deceased by the health system. As hospitals are sometimes utilised by custodial authorities it is important to note breaches of a number of recommendations in four of the cases (28NSW; 37NSW;  8VIC; and 36VIC).

Table 8.6 shows that the breaches concerned recommendations directed at cross-cultural awareness. They were generally not detected by Coroners and occurred mostly in the first period. The four cases occurred in New South Wales and Victoria. State and territory governments generally only claimed part implementation of these recommendations (see Part C Appendix).

Table 8.6 Non-Custodial Health

Recommendation 247 - Training
That more and/or better quality training be provided in a range of areas taking note of the following:

1. Many non-Aboriginal health professionals at all levels are poorly informed about Aboriginal people, their cultural differences, their specific circumstances and their history within Australian society. The managers of health care services should be aware of this and institute specific training programs to remedy this deficiency, including by pre-service and in-service training of doctors, nurses and other health processionals, especially in areas where Aboriginal people are concentrated;
2. The rotation of staff through country hospitals means that many professional staff are ill-prepared to provide appropriate health care services to Aboriginal people. staff on such rotations should receive special training for their rural placements, and resources to make this possible should routinely be provided as part of the operating budgets of the relevant facilities;
3. The primary health care approach to health development is highly appropriate in the Aboriginal health field, but health professionals are not well trained in this area. The pre-service and in-service training of doctors, nurses and other health professionals should provide such staff with a firm understanding of and commitment to primary health care. This should be a special feature of the training of staff interested in working in localities where Aboriginal people are concentrated;
4. Health care staff working in areas where Aboriginal people are concentrated should receive specific orientation training covering both the socio-cultural aspects of Aboriginal communities they are likely to be serving and the types of medical and health conditions likely to be encountered in a particular locality. Such orientation programs must be complemented by appropriate on-the-job training.
5. Effective communication between non-Aboriginal health professionals and patients in mainstream services is essential for the successful management of the patients' health problems. Non-Aboriginal staff receive special training to sensitive them to the communication barriers most likely to interfere with the optimal health professional/patient relationship; and
6. Aboriginal people often present to mainstream health care facilities with unusual health conditions and unusual presentations of common conditions as well as urgent, life-threatening conditions. The training of health professional must enable them to cope successfully with these conditions.

In the case of the man who died at Gippsland Base Hospital (8VIC) the deceased was initially taken to the hospital by ambulance after suffering an epileptic fit. When examined by the Resident Medical Officer (RMO) he became quite aggressive and subsequently began to behave in an irrational and incoherent way. The Coroner found that the inexperienced RMO reacted to the deceased as 'an aggressive, volatile, drunken Aboriginal'. The nurse also formed a similar opinion. Police were called. On arrival they formed a similar opinion of the deceased and took him from the hospital. They refused the request of the RMO for them to assist in his examination as there was a shortage of staff at the police station. The Coroner found the conclusion of the medical officer and nurse was surprising as the deceased had arrived in an ambulance after having suffered an epileptic seizure. This case may be taken to demonstrate the need for the training of medical and nursing staff in the misconceptions and stereotypes associated with Aboriginal people and intoxication.

In the case of an man who died at Prince Henry Hospital (ex Long Bay Prison) (37NSW) the deceased had heart disease. He had attended Walgett Hospital on 14 February 1992 complaining of a 'pain in the gut' and was treated for angina. While the Coroner found that their actions were justified, a fuller examination by hospital staff was found to be in order, particularly given the propensity of Aboriginal people to heart disease and that stomach pains are often reported as symptoms. (See for example, the deaths at Broken Hill Prison (71NSW) and Mobilong Prison (20SA)).

Recommendation 252 - Casualty Procedures
That hospitals that are regularly attended by Aboriginal people should review existing procedures in casualty, in consultation with Aboriginal Health and Medical Services, to reduce the likelihood of  Aboriginal patients receiving ineffective diagnosis and treatment. The usefulness of standard protocols in such situations should be explored in the reviews.

In three deaths Aboriginal patients were misdiagnosed by hospitals. Two of the deaths (37NSW, 8VIC) are discussed under recommendation 247. In the case of the woman who died in a Police van in Prahran (36VIC) the deceased had taken an overdose of theophylline tablets. The doctor at Albert Hospital stated that she smelt of intoxicating liquor but evidence of intoxication was not found in the post-mortem reports. The hospital subsequently released the deceased at her own request and against their advice.

Recommendation 253 - Design and Methods in Hospitals
That the physical design of and methods of operating health care facilities be attuned to the needs of the intended patients. Particularly where high concentration of Aboriginal people are found, their special needs in these regards should be taken into consideration. The involvement of Aboriginal people in the processes of designing such facilities is highly desirable.

In the case of the man who died at Prince Henry Hospital (ex Long Bay Prison) on 12 June 1991 (26NSW) there was no emergency alarm button in the Prison Annex at the Hospital. This oversight did not contribute to the deceased's death as support staff were able to quickly arrive. Nevertheless, the Coroner suggested an emergency button be installed.

The case of the man who died at Prince Henry Hospital (ex Long Bay Prison) on 5 March 1992 (37NSW) (see brief factual outline under recommendation 247) clearly evidences the necessity for greater staff awareness regarding the prevalence of heart disease among Aboriginal people.

Recommendation 255 - Negative Stereotypes
That the holding of negative stereotypes of both Aboriginal people and people with drinking problems be addressed through effective staff selection and supervision, along with pre-service and in-service education, to reduce the ignorance, and through clear instructions by employing authorities that such stereotyping of Aboriginal people and those with drinking problems will not be tolerated in the health care setting.

In the two Victorian cases (8VIC, 36VIC) doctors assumed the deceased was under the influence of alcohol. In the case at Gippsland Hospital (8VIC) the deceased had just had an epileptic fit. In the case at Albert Hospital (36VIC) the deceased had taken an overdose of theophylline tablets, but the doctor stated that she smelt of intoxicating liquor. Evidence of this was not found in the post-mortem reports.

Recommendation 263 - Non-Compliance with Medical Advice
That where there is a high level of non-compliance by a range of Aboriginal patients with advice tendered to them by health professionals, the health professionals should examine their styles of operation with a view to checking whether those styles cen be improved.

The death at Prince Henry Hospital (37NSW) raises issue of non-compliance with medical advice. The deceased had first attended Walgett Hospital on 8 February 1992 and subsequently failed to attend the doctor the next day as advised by the nurse. The deceased then attended the hospital again on 16 February 1992 complaining of a 'pain in the gut'. He was advised to see the Aboriginal Medical Service but failed to do so. The case raises the issue of non-compliance with advice. The style of operation of the health professionals involved is difficult to assess on the material.

 ENDNOTE

1. Sunday Times, 10 March 1996, at p.3.

2. See for example: New South Wales Corrections Health Service, First Annual Report, p.27-9; and coronial inquest into the death at Parklea Prison on 13 December 1994 (67NSW).

3. It also raises questions as to resources available to Corrections Health Services. See section 6.3.

4. See chapter 12.2

5. The cases are 39NSW, 42NSW, 50NT, 96NT, 3QLD, 5QLD, 21QLD, 25QLD, 32QLD, 38QLD, 53QLD, 1SA, 29SA, 8VIC, 31VIC, 38VIC, 2WA and 65WA.

6. 50NT, 96NT. In the former case the deceased's family has not been located and in the latter case the inquest has not commenced.

7. There is no information as to influence of alcohol or drugs in the cases of 1SA and 96NT. In the case of the woman who died at Macquarie Fields (39NSW) the deceased was withdrawing from drugs.

8. See also the death at Kempsey Police Station (A3NSW).

9. The Northern Territory case was not listed as a breach or recommendation 137, the inquest has not been included.

10. Aboriginal Legal Service, Striving for Justice Vol 3: Report on the Western Australian Government's Implementation of the Recommendations of the Royal Commission into Aboriginal Deaths in Custody, 1996, p.116

11. Steene, M., 'Watchhouse 'Not Told Prisoner Was Suicidal'', Townsville Bulletin, 7 July 1994, p.1.

12. Australian Institute of Criminology, Deaths in Custody Australia No 8: Australian Deaths in Custody and Custody-Related Police Operations, 1993-94, February, 1995, p13; McDonald, D., and D. Biles 'Methodological Issues in the Calculation of Over Representation and Exposure to Risk in Custody' in Deaths in Custody Australia, 1980-89: Research Papers of the Criminology Unit of the Royal Commission into Aboriginal Deaths in Custody Institute of Criminology, Canberra, 1992, p.444 (and research papers 7, 10 and 11 in that volume).

13. Royal Commission into Aboriginal Deaths in Custody, Report of Inquiry into the death of Misel Waigana pp12-17, 28-35, 40-50.

14. Correspondence between Human Rights Commissioner Sidoti and Senior Constable Craig Fraser, Property and Facilities Branch, Queensland Police Service, 24th January 1996.

15. House of Representatives Standing Committee on Aboriginal and Torres Strait Islander Affairs, Justice Under Scrutiny: Report of the Inquiry into the Implementation by Governments of the Recommendations of the Royal Commission into Aboriginal Deaths in Custody, November 1994, p.223 ('Justice Under Scrutinty').

16. 68SA, 73SA, 77SA, 78SA, 82S and 84SA.

17. Justice Under Scrutiny, op. cit.,p.223.

18. See Curry, R 'You Wouldn't Put Your Dog in Them', Framed, No. 31, Spring 1996, p.3 on safe cells in New South Wales prisons.

19. National Report, Volume 3, p.275-6.

20. See, Curry, op. cit., on conditions in safe cells in New South Wales.

21. Correspondence from Wayne Chivell, South Australian State Coroner, dated 24 September 1996.

22. This is also despite the reflection of the Royal Commission recommendation in 5.68 of the Standard Guidelines for Corrections in Australia accepted by Corrective Services Ministers in May 1994.

23. The drug and alcohol worker noted this fact in the form. However, there was no question dealing with this situation and no procedures to follow.

24. National Report, Vol. 3, p.272.

25. See recommendation 60 for a further discussion of these cases.

26. Kennedy, F State Asks for Report on Noose Charges Australian, 22 July 1992, p5.

27. R v Button (Unreported, District Court of WA, Hammond CJDC, 3 May 1996).

28. Government of New South Wales, Implementation of Government Responses to the Recommendations of the Royal Commission into Aboriginal Deaths in Custody: New South Wales Government Report, Vol.1, 1993/94 p62-63 ('NSW Implementation Report 1993/94').

29. Australian Institute of Criminology Deaths in Custody Australia No 8: Australian Deaths in Custody and Custody-Related Police Operations, 1993-94 February 1995 p13; McDonald and Biles 'Methodological Issues in the Calculation of Over Representation and Exposure to Risk in Custody' in Deaths in Custody Australia, 1980-89: Research Papers of the Criminology Unit of the Royal Commission into Aboriginal Deaths in Custody Institute of Criminology, Canberra, 1992, p.444 (and research papers 7, 10 and 11 in that volume).

30. Ibid.

31. NSW Implementation Report 1993/94, op. cit., p 63-64.

32. South Australian ALRM & AJAC Independent Royal Commission into Aboriginal Deaths in Custody Monitoring Report, January 1995 - June 1996, p78.

33. Sykes, Dr R, Report to the New South Wales Department of Corrective Services on Aboriginal  Recruitment and Career Enhancement, March 1995.

34. The deceased was an extraordinarily gifted artist. One of his paintings appears on the cover of the 1996 Queensland Overview Committee Report.

35. In the case of the 35 year old man who died at Townsville Prison (64QLD) the deceased was in isolation on request due to the nature of the offences for which he was on remand. The Prison Manager reported that he deceased had access to the library and was regularly visited by ATSIC councillors, guards and professional staff.

36. Rev James S Hassall, In Old Australia RS Hughes & Co Elizabeth St, Brisbane 1902.

37. Ibid, p106.

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A Report prepared by the Office of the Aboriginal and Torres Strait Islander Social Justice Commissioner

for the

Aboriginal and Torres Strait Islander Commission