Row Row, Frederick Arthur James

Contributing factors

• Rapid downward reassessment of suicide risk from high to low in less than 48 hours despite minimal change in risk factors
• Inadequate risk assessment on morning of death despite new presentation of distress and fleeting suicidal ideation
• Over-reliance on verbal denial of suicidal ideation without consideration of impulsivity and cultural factors affecting First Nations prisoners
• Failure to recognise significance of acute stressors: assault aftermath, family deaths, concerns about lengthy imprisonment
• Lack of continuity of psychological care with different assessors over 3 days
• Insufficient consideration of shame and cultural isolation as risk factors in First Nations male
• Absence of anxiety reduction strategy despite high anxiety about assault victim's condition
• Inadequate documentation and communication of risk and protective factors in Risk Assessment Team process
• Risk Assessment Team meeting minutes prepared in advance without meaningful discussion, with recommendations potentially predetermined
• Procedural non-compliance: exercise yard door left open without continuous observation, contrary to Risk Management Practice Directive
• Inadequate staffing in Detention Unit - single officer left prisoners unsupervised while collecting meals
• Insufficient detail in Safety Order regarding exercise yard door access
• Environmental hazard: open internal door to exercise yard provided accessible hanging point in 'sterile' containment unit
• Delay in obtaining Mr Ford's medical status information, prolonging Mr Row Row's acute anxiety and distress

Coroner's recommendations

1. Refer findings to Closing the Gap Partnership Committee for consideration in implementation of strategies for culturally appropriate mental health responses for First Nations prisoners
2. Consider development of risk assessment protocols and forms specifically designed for First Nations prisoners that reflect cultural sensitivities and recognise higher rates of impulsivity and fewer warning signs before suicide
3. Implement targeted recruitment of male psychologists to provide culturally appropriate services for First Nations male prisoners
4. Enhance training in risk assessment, particularly regarding unique risk factors and presentations in First Nations prisoners
5. Strengthen cultural awareness training for all correctional and health staff involved in assessments and care
6. Implement continuity of care principles where operationally feasible, particularly for assessment by the same clinician over time
7. Ensure Risk Assessment Team meetings include genuine discussion and debate rather than predetermined recommendations
8. Improve documentation standards for risk and protective factors assessment with quality assurance by senior staff
9. Develop and implement formal anxiety reduction and suicide risk management strategies for at-risk prisoners with identified stressors
10. Ensure adequate staffing levels to maintain continuous observation in Detention Units
11. Strengthen Safety Orders with explicit detail about management of exercise yard and other potential hanging points
12. Maintain closure of internal doors providing access to hanging points in cells designated for at-risk prisoners
13. Develop systems to obtain and communicate relevant clinical information (such as victim's medical status) to reduce acute anxiety in affected prisoners where confidentiality permits
14. Expand access to community mental health services and private providers within correctional settings
15. Increase funding and resources for psychological and mental health services in correctional centres to reduce reliance on risk assessment alone and enable ongoing therapeutic support