Coroner's Finding: TURNER Troy Phillip

Contributing factors

• failure to attempt resuscitation despite uncertain time of hanging
• absence of after-hours medical staff at prison
• inadequate emergency training of custodial staff
• accessible hanging points in cell design (shower cubicle)
• availability of strapping material from prison industries area
• absence of regular prisoner checks between 8pm and 8am
• depression and suicidal ideation while in custody

Coroner's recommendations

1. DCS and Group 4 review the language used in relevant procedures to ensure no uncertainty among custodial staff about their duty to resuscitate a prisoner in an emergency situation
2. Group 4 either provide a nurse qualified to provide emergency treatment 24 hours per day, 7 days per week at Mount Gambier Prison, or ensure custodial staff are adequately trained and equipped to provide appropriate emergency treatment pending arrival of ambulance officers
3. Group 4 take appropriate steps to ensure cells are designed in accordance with 'safe-cell' project principles to ensure hanging points are kept to a minimum
4. DCS and Group 4 put appropriate consultative procedures in place so that changes in DCS practices and procedures are implemented in Group 4-operated prisons without delay
5. Group 4 put appropriate procedures in place to ensure prisoners do not have access to hanging materials such as timber straps