Inquest into the death of Bernard Hector

Contributing factors

• inadequate documentation of reasons for 'at risk' court orders
• staffing shortages in corrections affecting supervision and appointment access
• missed medical and mental health appointments due to lockdowns and staffing
• lack of mechanism for prisoners to report concerns about themselves or others
• insufficient Aboriginal staff in correctional and health services
• closure of forensic mental health follow-up despite housing in normalized environment
• lack of regular health and safety checks during night shift in low-security housing
• fellow prisoners' observations of mental health deterioration not reported to staff

Coroner's recommendations

1. Chief Judge of the Local Court of the Northern Territory amend Practice Direction 12 to provide that written reasons are to accompany an 'at risk' order
2. Commissioner of the Northern Territory Correctional Services make available Aboriginal Mental Health First Aid Training to all prisoners
3. Correctional Services make efforts to recruit Aboriginal staff not only as correctional officers but to all employment classifications within Correctional Services, and endeavour to ensure that their Aboriginal employees are utilised throughout the prison and are available to all prisoners, in accordance with RCADIC recommendation 178
4. Commissioner of the Northern Territory Correctional Services and the CEO of the Northern Territory Department of Health together ensure that all prison health clients attend scheduled health appointments