Cockshutt, Andrew James

Contributing factors

• relationship breakdown with fellow prisoner
• poor information management systems failing to flag prior self-harm history
• prior self-harm incidents in 2002 and 2006 not systematically accessible to unit staff
• Integrated Offender Management System (IOMS) flagging system implemented late and did not capture historical incidents
• accommodation manager approved transfer without enquiring into reasons or considering prisoner history
• accessible hanging point (towel rail attached to cell wall at 150cm height)
• self-harm disclosure to other prisoners not reported to staff

Coroner's recommendations

1. Implementation of systematic flagging in IOMS for all prisoners with prior self-harm history dating back before late 2006 implementation of electronic flagging system
2. Review of all prisoner records prior to implementation of self-harm flagging system and update IOMS records accordingly
3. Amendment of QCS policy to require intelligence officers to note information regarding prisoners who may be incompatible for accommodation purposes
4. Eliminate hanging points from prison cells as recommended by Royal Commission into Aboriginal Deaths in Custody (RCADIC) 20 years prior
5. Complete capital works redevelopment of Lotus Glen Correctional Centre to include air-conditioning and removal of accessible hanging points from older cell blocks
6. Reduce positioning height of towel rails and other potential hanging points where structural modifications not yet completed