Inquest into the death of Robert Martin Johnson
Deceased
Robert Martin Johnson
Demographics
34y, male
Date of death
2010-01-23
Finding date
2012-03-07
Cause of death
asphyxiation by hanging
AI-generated summary
A 34-year-old Aboriginal male died by suicide while on remand in prison. Despite a history of suicide attempts in 2004-2005, reception screening failed to identify suicide risk, partly because electronic alerts were not consistently checked and the deceased denied previous self-harm. Critical warning signs emerged on his final day—telephone calls where he stated 'I don't feel like living anymore' and 'I just give up'—but these were not monitored by prison staff. The coroner found the at-risk assessment process relied too heavily on prisoner self-reporting and the 'smiley face' test, which lacked cross-cultural validity. Key lessons: electronic health alerts must be systematically accessed during reception; recorded calls warrant selective monitoring for suicide risk indicators; Aboriginal prisoners require culturally appropriate mental health screening; and prisons need Aboriginal liaison officers, staff mental health training, and robust response to disclosed suicidal ideation, regardless of recent presentation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
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
- 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
- Prison officers and medical personnel receive Mental Health First Aid training (or equivalent) with annual maintenance training
- The 'happy/smiley face' test, as an 'at risk' assessment tool, be replaced with a cross culturally appropriate and validated assessment tool
- 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
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