Inquest Into The Death Of Luke Anthony Rich

Contributing factors

• inadequate observation regime - reliance on CCTV rather than in-person contact
• cell design with known ligature points in rear doors
• failure to replace doors identified as unsafe in 2020
• insufficient staffing resources
• staff not briefed on known environmental risks
• inadequate implementation of COVID-19 isolation mitigation measures
• failure to identify and address covered cameras as safety concern
• extended isolation in what amounted to solitary confinement
• loss of employment, relationship breakdown, recent heavy drug use

Coroner's recommendations

1. ACTCS publish guidance to staff pursuant to s 14 of the Corrections Management Act 2007 (ACT) addressing: the purposes of detainee observations; how observations are to be recorded; the role that CCTV is to play in the observation process; and what is to be done when cameras are intentionally covered by detainees
2. External consultants be engaged to assess the safety of the rear doors in the Management Unit in light of the evidence in the inquest; and the outcome of that review be published
3. A Suicide Prevention Framework for ACTCS be developed as a priority; it gives expression to the need for suicide prevention to be accepted as shared responsibility at the AMC; the terms of the Victorian Framework be considered in that process; and an attempt be made to assess the efficacy of the introduction of the Framework in the Victorian Prison system and reflect those learnings in the process of developing the framework document to apply at the AMC