Coronial
NSWcustody

Inquest into the death of Phillip Boney

Deceased

Phillip Mitchell Boney

Demographics

43y, male

Coroner

Decision ofDeputy State Coroner Ryan

Date of death

2022-09-04

Finding date

2024-08-08

Cause of death

hanging

AI-generated summary

Phillip Mitchell Boney, a 43-year-old First Nations man, died by hanging in a correctional centre cell containing an obvious ligature point (exposed metal railings). He was under extended supervision in the community when his 22-year-old son died in 2021, profoundly affecting his mental health. After breaching his supervision order, he was returned to custody and transferred between two facilities. Critical gaps emerged: receiving health staff were unaware of his son's recent inquest, cell placement decisions didn't account for his heightened risk despite documented mental health vulnerabilities, and obvious hanging points in cells were never removed despite previous risk assessments. Mental health care was adequate in isolation, but systemic failures in information sharing between facilities, cultural considerations, and environmental safety measures meant preventable risk factors were not mitigated. Key learnings include the importance of communicating significant life events between correctional facilities, considering First Nations inmates' family and cultural connections in placement decisions, and urgently removing ligature points from cells.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrygeneral practicecorrectional health

Error types

communicationsystemdelay

Drugs involved

mirtazapinequetiapine

Clinical conditions

depressiongrief and bereavementself-harm historysuicidal ideation

Contributing factors

  • inadequate transfer of critical mental health information between facilities
  • lack of awareness by receiving health staff of recent traumatic inquest into son's death
  • cell placement not protective despite documented suicide risk factors
  • exposure to obvious ligature point in cell
  • disconnect from family, culture, and country during extended supervision
  • inability to return to Moree where family was located
  • profound grief and loss following son's death
  • depression and previous self-harm history

Coroner's recommendations

  1. Immediate steps be taken to remove all hanging points from John Morony Correctional Centre and expedite identification and removal of hanging points in all NSW correctional centres
  2. Development of a written procedure for supervising First Nations offenders under the Crimes (High Risk Offenders) Act 2006 to supervise them in their own community/on country or in communities where they have strong family/cultural connections
  3. Extended Supervision Teams assess as part of bi-monthly case plan reviews whether plans to support First Nations persons around cultural needs remain appropriate and document reasons for conclusions
  4. Acting Commissioner of CSNSW consider employment/engagement of culturally appropriate psychologists as part of the Violent Offenders Treatment Program
  5. Attorney-General amend the Crimes (High Risk Offenders) Act 2006 to expressly recognise importance of First Nations persons maintaining connection to family, community, culture and country, and require consideration of cultural needs in ESO applications
  6. Minister for Corrections amend clause 20(1) of the Crimes (Administration of Sentences) Regulation 2014 to expressly require regard be had to preference for placement with family members in custody
  7. Justice Health and Forensic Mental Health Network consider the findings in developing the Health Problem Notification e-form
  8. Justice Health and Forensic Mental Health Network, in consultation with CSNSW, review efficacy of systems concerning electronic alerts around mental health risks auto-populated into correctional services systems
Full text
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