McGeary, Corey Allan

Contributing factors

• Chronic risk of self-harm due to complex psychiatric comorbidity: severe personality disorder, history of suicide attempts, schizophrenia diagnosis, mild intellectual disability, dysfunctional family relationships, severe childhood trauma
• Stressful prison transfer precipitated acute emotional distress
• Inadequate staff response to visible distress: failure to involve mental health staff despite knowing prisoner objected to transfer
• Lack of psychological support consultation before destabilising event
• Exposed bars in cell providing accessible ligature point
• Impulsivity associated with psychiatric condition

Coroner's recommendations

1. The Department of Corrective Services should investigate the feasibility of having counsellors or psychologists identify, during initial prisoner assessment, those at chronic risk of self-harm (not necessarily acute) who should be flagged to require mental health involvement whenever defined stressful events are likely to impact them, such as transfers.
2. The State Government should immediately provide sufficient funding to remove exposed bars in all cells at Arthur Gorrie Remand and Reception Centre to eliminate hanging points.