Coroner's Finding: COOK Damian John

Contributing factors

• suicidal ideation not detected by staff
• lack of ongoing risk screening during custody (only done at admission)
• obvious hanging point accessible in cell
• single cell occupancy allowing unobserved opportunity
• failure of staff to observe or act on earlier self-harming behaviour (wrist cuts observed by inmates but not reported to staff)
• poor communication between inmates and staff regarding fellow inmate welfare
• deteriorating mental health due to relationship breakdown and inability to see daughter
• difficult phone conversation with ex-partner preceding the death

Coroner's recommendations

1. DCS forthwith remove or modify the hanging points in Cell 20, Unit 4 identified in this Inquest so as to eliminate or minimise to the greatest extent possible the risk that they will be used by an inmate for the purpose of self-harm or suicide.
2. In so far as those same potential hanging points exists in other cells in the ARC, that the DCS forthwith remove or modify them so as to eliminate or minimise to the greatest extent possible the risk that they will be used by an inmate for the purpose of self-harm or suicide.
3. All other hanging points within the cells at the ARC be identified and either removed or modified so as to eliminate or minimise to the greatest extent possible the risk of an inmate using them for the purpose of self-harm or suicide.
4. The 'safe cell' principles be adopted and implemented by the DCS in prisons throughout South Australia and done so as a matter of urgency.
5. DCS expedite its current audit and then, as a matter of urgency, make a further submission to Government for the necessary funding to implement safe cell principles in prisons throughout South Australia.
6. The South Australian Government, upon receipt of such further submission from DCS, reconsider its earlier decision not to accord priority to the implementation of the safe cell principles in prisons throughout South Australia.
7. Continuing efforts should be made by DCS to encourage prisoners to pass on concerns or information they may have that a fellow prisoner may be at risk either to custodial officers, Aboriginal Liaison Officers, or any other appropriate person.
8. DCS make continuing efforts to educate prisoners, and families, friends and associates, of the urgent need to pass on any concerns about the mental health of a prisoner to the medical or custodial authorities at the prison so that adequate measures can be taken to protect the prisoner from self-harm.
9. DCS place in visitor's waiting areas in the ARC information that would enable a visitor or other person concerned for the welfare and safety of an inmate, particularly in relation to the possibility of self-harm, to register formally their concerns.
10. DCS establish a formal procedure to enable expressions of concern so made to be registered and acted upon by ARC staff.
11. DCS establish a panel to examine the feasibility of introducing a regime whereby inmates at the ARC are formally screened for risk of self-harm on a more regular basis.