Coroner's Finding: COSTI John Steve

Contributing factors

• single cell accommodation with available hanging point
• inadequate observation frequency (two-hourly intervals)
• predictable patrol patterns allowing sufficient time for suicide
• no formal risk reassessment after trial postponement and bail refusal
• no post-court screening procedures for distress in non-HRAT prisoners
• access to ligature material (bedding strips)
• prolonged remand period (351 consecutive days)
• trial postponement and unsuccessful bail application six days before death

Coroner's recommendations

1. That the Department for Correctional Services implement the draft revised paragraph 3.3.9 of SOP 90 requiring correctional officers to check all prisoners returning from court (including video conferencing) for signs of distress and immediately report concerns to responsible officers, with this requirement to apply to all prisoners regardless of HRAT status
2. That the Department for Correctional Services amend SOP 97 to ensure observations of prisoners are conducted at intervals no less frequently than one-hourly and are conducted randomly and not always in the same sequence to avoid becoming predictable, with necessary human resources made available
3. That the Department for Correctional Services ensure that safe-cell design takes into account the hanging point used by Mr Costi and eliminate this hazard from cell accommodation