Inquest into the death of Dimitrios MAVRIS
Deceased
Dimitrios Mavris
Demographics
48y, male
Date of death
2018-05-25
Finding date
2021-02-19
Cause of death
hanging
AI-generated summary
Dimitrios Mavris, a 48-year-old man arrested for drug importation, died by hanging in the Surry Hills Cells Complex on 25 May 2018, approximately 40 hours after being taken into custody. He was initially assessed as presenting no suicide risk and was not placed on an Immediate Support Plan (ISP). However, between 11:50am and 1:40pm, CCTV footage captured Mr Mavris fashioning a ligature and attempting self-harm, but no officer observed this because the Monitor role duties were misunderstood—officers did not perform general CCTV observations of inmates without an ISP. Between 6:10pm and 6:30pm, Mr Mavris completed a fatal hanging while officers in the reception area watched television on CCTV screens. The coroner found critical failures in monitoring practices, including the misapplication of the Monitor role, officers watching television whilst on duty in breach of policy, inadequate CCTV quality standards, and lack of consistent use of the Morseman Tour Guard Wand for physical cell checks. The coroner made five recommendations directed at clarifying the Monitor role, upgrading CCTV systems, training on vigilance standards, reviewing a senior officer's conduct, and implementing regular physical cell inspections.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- misunderstanding of Monitor role duties resulted in failure to observe CCTV footage for signs of self-harm
- officers watching television whilst on duty, reducing vigilance
- failure to place deceased on Immediate Support Plan despite observable self-harm attempts
- inadequate CCTV footage quality, particularly after cell lights turned off
- non-compliance with Morseman Tour Guard Wand requirements for regular physical cell inspections
- cell architecture providing multiple hanging points
- availability of materials (shirt, blanket, plastic knife) to fashion ligature
- shift change at 2:00pm with no handover communication regarding self-harm attempts observed earlier that morning
Coroner's recommendations
- Amend post duties of the Monitor role at Surry Hills Cells Complex and Local Operating Procedure 2019/04 to explicitly state that the Monitor must regularly observe CCTV footage of inmates in cells for identifying behaviour indicating risk of suicide or self-harm
- Conduct urgent review of CCTV cameras in cells and display screens in reception area to determine whether CCTV footage is of sufficient quality to identify inmate behaviour indicating risk of suicide or self-harm at all times, and implement Local Operating Procedure regarding timing and circumstances of cell lights being turned off and impact on CCTV footage quality
- Provide appropriate training to CSNSW officers rostered on duty at Surry Hills Cells Complex regarding Part 1 of Court Escort Security Unit Standard Operating Procedures on impermissibility of watching television whilst on duty, and conduct periodic audits by General Manager to ensure compliance
- Review conduct of Assistant Superintendent Dean Yarnton for possible disciplinary action in relation to countenancing television watching by subordinate officers whilst on duty and not utilising the Monitor role for its intended purpose
- Implement Local Operating Procedure for Surry Hills Cells Complex providing for correctional officers to physically attend cell of inmate with sufficient frequency (at least twice during each Watch) to ensure safety and well-being, and use Morseman Tour Guard Wand to confirm such attendances
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