Coroner's Finding: SMITH Arthur Charles

Contributing factors

• borderline personality disorder with chronic self-harming behaviour
• unpredictable and severe mood instability
• inadequate communication of suicide risk status to custodial staff
• accessible ligature point (metal towel rail) in cell
• premature discharge from infirmary to general population
• lack of double-occupancy cells available for observation
• insufficient psychology resources in prison system
• inadequate environmental safety measures

Coroner's recommendations

1. The Department for Correctional Services should make a renewed effort to implement the recommendation to remove all towel rail hanging points from cells as a high priority, as this poses an obvious ligature risk to at-risk prisoners
2. Reiterate previous recommendations made in inquests in relation to safe cell practices
3. Consider implementation of a visual alert system (such as a yellow dot system on cell doors) at Yatala Labour Prison to alert custodial staff that a prisoner is on suicide risk assessment, similar to the system at Adelaide Remand Centre
4. Increase capacity for double-occupancy cells in protective custody units to allow observation of high-risk prisoners
5. Increase psychology resources within the South Australian prison system to address the severe shortage identified (one psychologist at Adelaide Remand Centre and one to two at Yatala, compared to ninety-five in New South Wales)