Coroner's Finding: STACHOR Joshua Marek
Deceased
Joshua Marek Stachor
Demographics
30y, male
Date of death
2017-11-19
Finding date
2021-06-28
Cause of death
Hanging
AI-generated summary
Joshua Stachor, aged 30, died by hanging in Yatala Labour Prison on 19 November 2017. He was a remand prisoner on charges of domestic violence. The coroner found critical failures in his admission assessment on 6 November 2017. Mr Stachor had a documented history of self-harm attempts and had previously been placed under the High Risk Assessment Team (HRAT) regime during an earlier 2017 remand. Despite clear indicators of mental health deterioration (anxiety, paranoia, disclosed childhood sexual abuse), a Notice of Concern was never raised, and he was housed in a mainstream cell with multiple ligature points rather than receiving HRAT monitoring. The admission interview was conducted by inadequately trained staff without proper supervision. The coroner found a Notice of Concern should have been raised and that HRAT supervision, while not guaranteed to prevent his death, would have reduced the likelihood. Key systemic failures included insufficient training for admission interview officers, poor flagging of previous HRAT involvement, inadequate supervision during admissions, and unsecured ligature points in cells.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Failure to raise a Notice of Concern on admission despite indicators
- Inadequate admission interview training for correctional officer conducting interview
- Previous HRAT history not sufficiently highlighted on admission documents
- Inadequate supervision of admission interview by senior officers
- Placement in mainstream single cell rather than under HRAT monitoring
- Multiple ligature points available in cell
- Mental health deterioration during remand not identified or acted upon
- Contaminated admission paperwork and Justice Information System entries
- Lack of coordination between prison health and correctional staff at admission
Coroner's recommendations
- Department for Correctional Services continue to identify and eliminate hanging points from cells in all South Australian correctional facilities
- Chief Executive of DCS identify and appoint correctional officers specifically dedicated to admitting prisoners, thoroughly trained in admission process, Justice Information System use, and access to full historical information including prior HRAT involvement
- Officers specialising in admissions be subject to continuing education and training with mandatory hours per calendar year, including concentration on Notices of Concern, mental health basics, and physical signs of mental health problems
- Admission documents clearly and easily highlight any previous placement onto HRAT regime
- Chief Executive of DCS mandate a second Prisoner Stress Screening Form interview upon completion of first seven days observation and when proposing single cell accommodation or transfers
- All admission forms (electronic or paper) be reviewed to improve ease of use for correctional officers and prisoners
- Preferred method for admission be by computer records that are easily accessible and formatted
- HRAT team members be present for all admission interviews with input into whether Notice of Concern should be raised
- In alternative, HRAT be automatically notified when a prisoner previously under HRAT care is readmitted and conduct formal reassessment of whether HRAT should apply
- Electronic Prisoner Stress Screening Form be created with automatic alert when Notice of Concern needs to be raised and instant notification to HRAT by end of next day
- Items with potential to act as ligatures be classified as contraband in DCS institutions, or at least those with non-compliant safe cell designs
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