O'Connor, Scott Matthew

Contributing factors

• Failure to conduct observations as prescribed (both physical and visual) every 30 minutes despite clear instructions
• Misinterpretation of observation requirements by monitoring staff
• Covered CCTV camera in exercise yard not detected or addressed for over 24 hours
• Inadequate staffing in Maximum Security Unit (two officers instead of three minimum) during training afternoon
• Supervisor failure to remove staff to alternative supervision or replace staff lost to training
• Risk Assessment Team meeting conducted without authors of assessment reports present
• Absence of custodial staff contribution to Risk Assessment Team regarding cell infrastructure and hanging points
• Mental health and psychology staff unaware of hanging points and cell hazards
• Falsified observation logs recorded retrospectively after discovery of death
• Access to ligature material (bird cage cover made from sheet) not removed from cell
• Culture of complacency regarding observation protocols and covered cameras in Maximum Security Unit
• Inadequate handover of critical information regarding Mr O'Connor's deteriorating mental state on weekend

Coroner's recommendations

1. RAT meetings must assess adequacy of cell infrastructure, specific risks presented by proposed accommodation, and make recommendations about suitability of cells for at-risk prisoners
2. Conduct audit of all hanging points and ensure RAT members are aware of those risks
3. Install covert microphones in AGCC master control and MSU master control if reopened
4. Install CCTV in AGCC MSU master control room if reopened
5. Review rostering so officers conducting observations are familiar with the prisoner or extremely au fait with at-risk indicators
6. Ensure psychologist who undertook assessment is present at RAT meeting unless attending psychologist is familiar and current with prisoner
7. RAT meetings must have access to actual observation logs, not summaries
8. Supervisors from prisoner's accommodation area must be involved in RAT meetings and address environmental risks
9. Review rostering to identify officers on extended night-shifts and master control positions, provide varied rosters
10. Disciplinary action regarding CCO Lumsden for falsifying observations logs and regarding MSU Supervisors for failing to remove covered CCTV camera
11. Provide training to all relevant staff on management of at-risk prisoners including suicide prevention
12. Training to ensure officers understand necessity for comprehensive handover information
13. Training on proper development of at-risk management plans including accommodation section
14. Training on proper and vigilant implementation of at-risk management plans
15. Training to ensure psychologists and mental health staff aware of environmental risks
16. Training on proper completion of 'Instruction - At Risk Prisoner' document
17. Training to all staff on at-risk indicators and mechanisms for maintaining current suicide prevention training
18. Training incorporating awareness of risks from apparent improvements in demeanour of at-risk prisoners
19. Training on increased suicide risk in isolation, seclusion or administrative segregation
20. Training on environmental and operational factors contributing to suicide
21. Urgent training for RAT members on suicide resistant bedding and clothing
22. Significant training for RAT members on all matters to be assessed and responsibility allocation
23. Significant training for all staff on conducting proper at-risk observations and case noting, including interpretation of instructions, escalation procedures, and detailed documentation requirements