Coroner's Finding: MORGAN Martina
Deceased
Martina Morgan
Demographics
60y, female
Date of death
2015-03-20
Finding date
2019-12-20
Cause of death
neck compression by ligature strangulation
AI-generated summary
Martina Morgan, aged 60, died from ligature strangulation by her own leggings while in police custody at Sturt Police Station in March 2015. She was significantly intoxicated (BAC 0.23%) and taking benzodiazepines when arrested for disturbing the peace. The coroner found that Ms Morgan should have been classified as 'high need' rather than 'medium risk' based on her gross intoxication, reported suicidal history, PTSD diagnosis, and assertion of recent overdose. Mandatory 15-minute observations and CCTV monitoring were inadequate. Her leggings were not removed despite being elastic and capable of use as a ligature. She removed her leggings unobserved at 9:10pm and collapsed at 9:15pm but was not discovered until 9:23pm. The coroner identified failures in risk assessment, inadequate observation protocols, failure to remove potential ligatures, and insufficient communication of care requirements to custody staff. Key recommendations include automatic 'high-need' classification for prisoners with self-harm history, mandatory removal of elastic garments, improved CCTV visibility for monitoring staff, and routine questioning about current suicidal ideation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- gross intoxication with alcohol (BAC 0.23%)
- concurrent benzodiazepine use (diazepam, temazepam) at therapeutic levels
- cannabis intoxication
- opioid use (oxycodone)
- incorrect risk assessment as 'medium risk' rather than 'high need'
- failure to remove elastic leggings despite General Order requirements
- inadequate observation protocols reliant on 15-minute checks rather than continuous monitoring
- CCTV monitors not continuously observed by custody staff
- failure to brief cell guard about risk assessment and care requirements
- silence from prisoner not recognized as concerning
- custody staff distracted with processing other prisoners
- complex mental health history including PTSD, suicidal ideation, previous suicide attempts
- recent psychiatric assessment indicating suicidal thoughts
Coroner's recommendations
- Review and establish a documented framework for staffing levels within SAPOL cell complexes
- Explore implementation of Radio Frequency Identification (RFID) scanners on each cell door for prisoner inspections to ensure checks are actually performed physically
- Amend SHIELD system to ensure automatic categorisation of detainees as 'high need' if they provide a positive response to questions relating to self-harm
- Amend SHIELD system to ensure custody records cannot progress until Digital Straightening Record (DSR) and SAPPS have been viewed prior to Risk Assessments
- Ensure cell staff utilise the 'time' field option on SHIELD when conducting prisoner checks
- Amend General Order Custody Management to specifically include leggings and similar elastic clothing in the definition of items to be removed from detainees, with consideration of alternative clothing provision and detainee dignity
- Relocate CCTV cell monitors in Sturt cells charge office to enable easier access and viewing by all cell staff
- Conduct full review of the operability and functionality of the Intercom System at Sturt cells
- Ensure that prisoners who are seriously drug and/or alcohol affected must be rated as 'high risk' even if they do not require immediate medical attention
- Redefine 'high need prisoner' to explicitly include those with past or current suicidal ideation or risk of self-harm, those whose behaviour cannot be safely predicted, and those incapable of self-care, requiring close observation and continuous risk assessment
- Implement mandatory questioning during custody screening about current (not just past) thoughts of self-harm and suicidal ideation
- Ensure cell guards are not assigned duties that distract from primary responsibility of safely and securely managing detainees
- Eliminate periods during which prisoners may not be under observation due to cell staff dealing with processing of new prisoners
- Record in SHIELD system any mental health incidents and warnings about mental illness for future reference in custody situations
- Specifically identify leggings and elastic garments in SAPOL General Orders as clothing posing risk and requiring removal from prisoners
Full text
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