Inquest into the death of Justin James Cordy
Deceased
Justin James Cordy
Demographics
34y, male
Date of death
2023-02-26
Finding date
2026-10-23
Cause of death
Hanging (suicide by ligature)
AI-generated summary
Justin Cordy, a 34-year-old man, died by suicide via hanging in the Alexander Maconochie Centre (AMC) prison on 26 February 2023 while on remand. The coroner found multiple critical system failures contributed to his death. Most significantly, inadequate controls allowed Justin unsupervised access to a wooden mop handle (used as a ligature point) left in his cell from the communal laundry, and to a razor he used to cut strips of bedding. Earlier failures included AFP officers' poor custody care and failure to seek mental health advice despite clear signs of self-harm at arrest; inadequate hospital assessment and failure to perform concussion screening; and absence of Mental Health Court Assessment and Liaison Service (MHCALS) on Saturday when he appeared in court, preventing mental health assessment and potential intervention. While these failures were identified as matters of public safety, only the equipment access deficiencies directly contributed to the cause of death. The coroner found that had adequate systems been in place controlling access to potential ligature points and weapons, the death would likely have been preventable.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Access to wooden mop/broom handle as ligature point from communal laundry
- Access to razor blade used to cut bedding strips for ligature
- Inadequate systems for checking cells and controlling equipment in corrections facility
- Failure to restrict detainee access to cleaning equipment during lock-in periods
- Recent relationship breakdown and discovery of partner's infidelity
- History of suicidal ideation and prior suicide attempt in custody
- Recent release from custody followed by re-incarceration after 4 days
- Ongoing substance misuse (methamphetamine, GHB, alcohol)
Coroner's recommendations
- Canberra Health Services should extend Mental Health Court Assessment and Liaison Service (MHCALS) to operate on all days on which bail hearings are held, including weekends and public holidays
- ACT Corrective Services should extend the controlled razor system used in SCC North (where razors are handed out and signed back in after use) to SCC West
- Correctional Officers should conduct and document regular spot checks on mop and broom storage system to ensure items are not retained by detainees for purposes other than cleaning
- Deputy Commissioner of Custodial Operations should revise the Cell Infrastructure Checks Operating Procedure to require corrections officers to physically enter cells during visual checks and define 'excess property' to include items not being used for their intended purpose
- ACT Corrective Services should publish guidance on observation practices including: shift briefings on staff responsibility for observations; instructions on new observation form; manner of undertaking and recording observations with requirement for contemporaneous documentation; and requirement to include details of detainee behaviour with specific examples
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