Coroner's Finding: ALLEN Craig Mark

Contributing factors

• Placement in isolated cell 211 against documented recommendation for shared cell accommodation
• Failure to review Health Assessment form containing self-harm risk history before placement decision
• Inadequate screening for suicide risk during cell 211 placement
• Isolation of prisoner with history of self-harm and prior attempted hanging
• Failure to communicate psychiatric history (depression, Prozac treatment) to correctional staff
• Failure to sight prisoner during scheduled night patrols in violation of Local Operating Procedure 26
• Inadequate patrol frequency (2-hourly intervals) for isolated at-risk prisoner
• Lack of continuous observation or CCTV monitoring in cell 211
• Insufficient induction and training of staff returning after prolonged absence
• Behavioural incident (jewellery refusal) treated as security/discipline matter rather than mental health concern
• Availability of hanging point (double bunk upper railing) in cell 211

Coroner's recommendations

1. Consideration be given to obtaining authorization under Section 36(2) of the Correctional Services Act 1982 for the cell 211 regime, as it involves keeping prisoners separately and apart from other prisoners
2. Continuation of the requirement (introduced January 2001) that a full audit of the case file and electronic case notes be undertaken within one hour of prisoner placement in cell 211 to identify at-risk issues
3. Implementation of routine disclosure of medical information by Prison Health Services to Correctional staff, especially where medical issues may impact prisoner management; legislation may be required to overcome privacy considerations
4. Increase frequency of observations for prisoners in cell 211 from two-hourly to hourly minimum
5. Consideration be given to installation of a remotely monitored CCTV camera in cell 211 and other management cells where prisoners are isolated for substantial periods of time
6. Elimination of all hanging points in cell 211 (noting the double bunk has been replaced with a single bed)
7. Provision of a comprehensive package of all Instructions, Duty Statements and Local Operating Procedures to Correctional Officers relating to their duties and responsibilities, with requirement to sign acknowledgment of receipt and reading
8. Implementation of formal Staff Induction Checklist (which has been introduced) with specific inclusion of patrol duties and protocols for night watch supervision
9. Ensuring staff returning after prolonged absence receive proper induction and training in division-specific procedures before commencing duties
10. Clear staff communication that all prisoners must be sighted on every two-hourly patrol (or more frequent patrols) with documented evidence in Watch Journals, and that this duty overrides prisoner comfort concerns about light disturbance