Coroner's Finding: Craig Anthony Behr
Deceased
Craig Anthony Behr
Demographics
male
Date of death
2004-03-27
Finding date
2010-12-14
Cause of death
Head injury caused by Michael Allan Heatley beating and kicking Craig Anthony Behr
AI-generated summary
Craig Anthony Behr, an inmate at Long Bay Correctional Complex, was killed on 27 March 2004 when placed in a cell with another inmate, Michael Heatley, despite explicit warnings three days prior from a forensic psychologist that Heatley posed a high risk of harm to others and was experiencing homicidal urges. The coroner found systemic and individual failures by Deputy Governor Lloyd and Assistant Superintendent Martin to properly implement, document, and communicate the psychologist's risk assessment to relevant staff. Officers Plumb and Smith failed to conduct adequate checks of the case file and inmate status before the cell placement. A 23-minute delay in responding to an emergency call from an adjoining inmate also hindered potential rescue. The coroner concluded the death was preventable had proper procedures been followed and recommended stronger protocols for documenting and communicating dangerous inmate status to all personnel.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Failure by Deputy Governor Lloyd and Assistant Superintendent Martin to implement forensic psychologist's explicit risk assessment recommendations
- Inadequate documentation and communication of Heatley's dangerous status to all relevant staff
- Failure to ensure Heatley remained in isolation (one-out cell placement)
- Systemic failures in prison management procedures and accountability mechanisms
- Inadequate checks by Officers Plumb and Smith of case file and documentation before cell placement decision
- 23-minute delay in responding to emergency knock-up call from adjoining cell
Coroner's recommendations
- Immediately upon a death in custody being notified to police, Corrective Services NSW must release control of all relevant documentation to NSW Police Critical Incident Teams such that the Critical Incident Team takes possession for examination and review of all relevant documentation from commencement of investigation and retains same until the Coroner directs otherwise
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