Coroner's Finding: CARTWRIGHT Stephen Andrew

Contributing factors

• Failure to recognize deceased as at-risk despite depression, anxiety, medication requirements, and alcohol intoxication
• Withholding of antidepressant and anti-anxiety medications despite prisoner requests
• Denial of telephone contact with family members
• Lack of physical welfare checks for 7 hours despite standing orders requiring hourly checks
• Failure to designate cell guard to monitor prisoner
• Open cell door providing hanging point using provided tear-able blankets
• Inadequate CCTV surveillance - monitors not directed to deceased's cell
• Use of standard woollen blankets susceptible to tearing
• Poor understanding of prisoner safety responsibilities by custodial staff
• Allocation of officer duties that left no one specifically responsible for cell welfare
• Inadequate training in prisoner risk assessment

Coroner's recommendations

1. Staff at Christies Beach Police Station be provided with proper training in relation to operation of the CCTV surveillance system on a regular and continuing basis to ensure all staff have working knowledge to readily manipulate the system to display any given cell or exercise area on any monitor or to scroll through all cells sequentially