Inquest into the death of Robert Martin Johnson

Contributing factors

• failure to identify suicide risk during reception screening despite prior history of self-harm attempts in 2004-2005
• electronic behavioural alerts not consistently accessed by reception officers
• over-reliance on prisoner self-reporting of mental health history
• inadequacy of 'happy face' test as culturally appropriate risk assessment tool
• prison staff not monitoring recorded telephone calls that contained clear suicide warning signs
• absence of Aboriginal liaison officers and culturally informed mental health staff
• lack of Mental Health First Aid training for prison officers
• ongoing stress from loss of contact with children due to care orders
• impact of adverse incident on 15 November 2009 potentially serving as background stressor
• no post-incident counselling or mental health follow-up after 15 November 2009 incident

Coroner's recommendations

1. Northern Territory Correctional Services increase the percentage of Aboriginal Liaison Officers and health workers in the prison system per head of prisoner population, with consideration being given to there being one Aboriginal Liaison Officer position for every major accommodation block
2. Prison officers and medical personnel receive Mental Health First Aid training (or equivalent) with annual maintenance training
3. The 'happy/smiley face' test, as an 'at risk' assessment tool, be replaced with a cross culturally appropriate and validated assessment tool
4. Northern Territory Correctional Services further investigate the incident that occurred between prison officers and the Deceased on 15 November 2009 in order to determine whether there were breaches of the directives or the Code of Conduct by any officer, and conduct any disciplinary proceedings as considered necessary