Inquest into the death of Anthony John Hayward
Deceased
Anthony John Hayward
Demographics
male
Date of death
1992-12-21
Finding date
1994-05-27
Cause of death
Suicide by cutting veins with razor blade
AI-generated summary
Anthony John Hayward, a prisoner at Berrimah Gaol, Northern Territory, died by suicide on 21 December 1992 by cutting his veins with a razor blade. The coroner's inquiry focused on prison administrative procedures rather than clinical care. Two contradictory prison instructions regarding razor issue were simultaneously in force: one requiring razors to be issued and collected daily (0730-0740 hours, 10-minute window), the other allowing overnight retention. Prison officers, unable to resolve the contradiction, implemented an unauthorised compromise permitting overnight razor access. Mr Hayward had special supervision arrangements requiring him to shave in front of an officer, but these were undermined when a fellow prisoner passed him a razor blade. The coroner found systemic administrative failures, poor documentation procedures, and lack of clear mechanisms for reporting inconsistencies contributed significantly to his death. Multiple recommendations addressed instruction clarity, documentation systems, training, and communication protocols within the prison system.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- Two contradictory prison instructions regarding razor issue in simultaneous force
- Prison officers implementing unauthorized compromise allowing overnight razor access
- Administrative failure in documentation and amendment procedures for instructions
- Lack of procedures for prison staff to report instruction inconsistencies
- Improper use of intercom system sanctioned by prison authorities
- Failure to follow daily issue and collection procedure (28B instruction) allowing overnight retention
Coroner's recommendations
- All Superintendent's instructions must be drafted with precision to accord with intended practice
- Amendments to Superintendent's Instructions must be properly documented with prior instructions expressly rescinded
- Manual of Superintendent's Instructions should be maintained in loose-leaf form with superseded instructions physically removed
- Indexing system for manual should be kept as simple as possible
- A register should be maintained recording dates when instructions became operative or ceased, including text of current and repealed instructions
- Only competent persons should be allocated to prepare and maintain the instruction manual
- Only competent persons should be allocated to maintain the amendment register
- Establish appropriate administrative procedures ensuring proper communication between Director of Custodial Operations and Prison Superintendent
- Upon induction, all prison officers should receive current copy of instruction manual
- Officer manuals should be kept up to date with instruction changes
- Meetings should be convened when instructions are amended to ensure all officers understand the changes
- All prison officers should receive adequate training in all Superintendent's Instructions
- Establish protocol for prompt reporting by prison staff of apparent inconsistencies in instructions
- Superintendent must give immediate and proper attention to any inconsistencies reported
- Prison procedures for razor issue should be uniform across all prisons in the system
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