Inquest Into The Circumstances Surrounding The Death Of Shannon Robert Camden
Deceased
Shannon Robert Camden
Demographics
21y, male
Date of death
1996-04-15
Finding date
1997
Cause of death
Suffocation from hanging
AI-generated summary
Shannon Robert Camden, a 21-year-old with longstanding mental health difficulties and previous suicide attempts, died by hanging in cell A1 of the Belconnen Remand Centre on 15 April 1996 while on remand awaiting trial for armed robbery charges. The coroner found that custodial officers failed to conduct proper 30-minute observations, with Mr Kelly appearing not to conduct any observations during the critical period when Camden died (likely around 4:30 AM). The coroner found that the quality of care, treatment and supervision by Mr Black (supervisor), Mr Kelly, Mr Gordon, and Mr Curbishley all contributed to the cause of death. Significant system failures included: lack of coordination between mental health services; inadequate facility design; failure of management to implement proper supervision; and a corrupted institutional culture where officers falsified observation records and gave perjured evidence. The coroner recommended prosecutions, facility improvements, establishment of a Corrections Health Board, and systemic reforms.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure to conduct required 30-minute observations
- Failure to conduct 15-minute observations of other detainees that would have required presence in yard
- Inadequate supervision by shift supervisor
- Failure to implement proper management protocols
- Facility design inadequacies
- Lack of psychiatric nursing support
- Lack of coordination between external mental health services and remand centre
- Delay in Mental Health Tribunal proceedings and assessments
- Change from 15-minute to 30-minute observations without documented rationale
- Failure to properly utilize Special Care Unit
- Lack of medical officer appointment as required by statute
- Absence of coordinated case management for mentally unwell detainee
- Decommissioning of Special Care Unit nursing and supervisory staff
Coroner's recommendations
- Prosecutions against John Michael Kelly, Bradley John Gordon, and Gavin Curbishley for perjury and attempt to pervert the course of justice
- Prosecution against Edward Grahame MacKenzie for attempt to pervert the course of justice and consideration of perjury charges
- Dismissal from Public Service of MacKenzie, Kelly, Gordon, and Curbishley
- Consideration of termination of employment of Arnoldus Marinus Joseph Van Hinthum
- Establishment of Corrections Health Board as matter of urgency
- Provision of adequate resources to mental health services for speedy assessments by Mental Health Tribunal
- Construction of new appropriate remand facility
- Complete external review of Belconnen Remand Centre operations
- Construction of proper mental health facility for detainees with mental health or behavioural problems (preferably attached to Canberra Hospital)
- Acquisition and installation of Automatic Guard Tour System for observations
- Superintendent to have access to all medical, correctional and welfare files relating to detainees
- Development of procedures for medical officer to access available medical information relating to detainees
- Development of protocols between BRC and all external agencies providing support
- Appointment of case managers by mental health service for people with mental dysfunction in custody
- Interagency protocols to provide access to relevant information with consent
- Mental Health Tribunal to receive thorough investigative assessments not just diagnostic assessments
- Government to accept and implement responsibility to provide necessary resources for safe custody
- Ensure Magistrates making MHT referrals arrange immediate advice to Office of Community Advocate
- MHT assessment requests be specific about questions and advice be clear about limitations
- MHT not rely on same service/professional for both assessment and involuntary treatment
- Changes to Mental Health Tribunal composition to avoid conflict of interest (magistrate should not preside over MHT while involved in criminal proceedings with same respondent)
- More careful preparation of applications before Mental Health Tribunal
- Consideration of impact of staffing shortages on detainee welfare and family contact
- Reactivation or proper operation of Special Care Unit
- Understanding by outside agencies of urgent nature of detainee support needs
- Appointment of full-time medical officer under Remand Centres Act
- Clear procedures for officer responsibilities and outside agency contact
- End to ad hoc documentation system at BRC
- Implementation of procedures ensuring information reaches relevant officers promptly with proof
- Feedback to officers on action taken regarding their reports
- Documentation of superintendent consultations and decisions on detainee movements
- Appointment of vigorous and robust superintendent to implement changes
Full text
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