Coroner's Finding: VARCOE Alexander Wayne Keith

Contributing factors

• failure to act on suicide risk screening form results at admission
• inadequate follow-up on history of self-harm and prior psychiatric assessment
• unreported prior sexual assault within prison
• inadequate cell design with multiple hanging points
• unresolved family separation issues and contact difficulties
• lack of immediate cellmate after cellmate transferred to infirmary
• inadequate investigation procedures that failed to determine time of death

Coroner's recommendations

1. The Department of Correctional Services review the Prison Stress Screening form in light of the issues discussed in this inquest, including clarification of when physical inspection for scars is required
2. The design of cells in E division at Yatala Labour Prison, and all older cells in the South Australian prison system, should be subject to comprehensive review along the lines of the Victorian Building Design Review Project to reduce hanging points
3. The Commissioner of Police reinforce with investigating officers and supervisors the need to comply with the protocol for investigation of deaths in custody, particularly in relation to determining the time of death, including ensuring pathologists are called to death scenes or alternative arrangements made