Coroner's Finding: Monson, Troy Colin; Michael, Robin and Mitchell, Scott Clifford
Deceased
Troy Colin Monson, Robin Michael, Scott Clifford Mitchell
Demographics
unknown
Date of death
2015-06-22
Finding date
2017-06-30
Cause of death
Troy Monson: asphyxia due to partially suspended hanging using seatbelt; Robin Michael: asphyxia due to hanging with shoelace ligature; Scott Mitchell: cardiac arrhythmia due to ischaemic heart disease and cardiomegaly from methylamphetamine use
AI-generated summary
This inquest examined three deaths in Tasmanian custody: Troy Monson (asphyxiation in prison van during transport in June 2015), Robin Michael (hanging in prison cell June 2015), and Scott Mitchell (cardiac arrhythmia from drug-induced cardiomegaly July 2015). Monson's death was preventable through multiple system failures: failure to identify suicide risk despite clear warning signs, inadequate assessment tools and tier processes, missing handover documentation between police and prison, failure to provide medical evaluation, and inadequate monitoring during escort. Michael and Mitchell's deaths were not preventable—Michael concealed suicidal intent from all staff, and Mitchell's cardiac event was unexpected in a young healthy-appearing prisoner. Key clinical lessons: structured suicide risk assessment must be completed and documented at custody entry; historical mental health records must be reviewed; medical information must accompany custody transfers; psychotropic medications should only be prescribed after face-to-face medical consultation; and regular monitoring during transport must be mandatory and documented.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Failure to identify Troy Monson as suicide risk despite documented history and expressed suicidal ideation
- Inadequate completion of corrections and health tier 1 assessments for Troy Monson
- Failure to raise mandatory SASH notification for Troy Monson
- Failure to raise risk intervention team assessment for Troy Monson
- Inadequate handover documentation from police to prison for Troy Monson
- Prescription of psychotropic medication without face-to-face medical consultation
- Failure to monitor prisoner during transport for Troy Monson
- Lack of face-to-face doctor availability at Launceston Reception Prison
- Inadequate escape-prevention features in seatbelts for Robin Michael
- Availability of shoelaces as ligature material for Robin Michael
- Methylamphetamine-induced cardiomegaly and coronary atherosclerosis in Scott Mitchell
Coroner's recommendations
- All police officers responsible for custody of detainees and cell watch duties be clearly reminded of duties under Tasmania Police Manual section 7.2, particularly order 7.2.10
- Fully up-to-date prisoner admission and assessment forms be provided by Tasmania Police to TPS at moment custody passes between agencies
- All TPS officers processing inmates undergo further training on proper processing method including checking inmates' records for previous custody episodes
- Adequate staff be rostered at all times at Launceston Reception Prison to enable correctional Tier 1 assessments as mandated by DSO 2.06
- CPHS nursing staff receive further training on completion of nursing (health) Tier 1 forms and be provided with computers to complete assessments
- TPS ensure appropriate staff mix available at Launceston Reception Prison to enable Risk Intervention Teams to operate per DSO 2.01 Order 14.1
- TPS amend Launceston/Hobart escort seating plan form to accord with categories in DSO 1.20 for External Escorts
- TPS review Emergency Operating Procedure 03 'Code Blue' regarding continuation of CPR in obviously futile cases
- Carrying of cut down knives by first and second response teams continue and cut down knives continue to be located in accommodation areas and escort vehicles
- Slip-on footwear replace all laced footwear for all prisoners and detainees in TPS
- Establishment of specialist TPS escort unit
- Purchase of appropriate vehicle for special escorts
- All prisoner escort vans in Tasmania be fitted with seatbelt type designed by Cartech Engineering Victoria for Corrections Victoria (centre-buckle, Kevlar-woven, 700mm length)
- TPS engage medical practitioner for face-to-face consultations at Launceston Reception Prison as needed
- Sufficient number of suitably trained medical practitioners always rostered by CPHS
- Proper evaluation of Prison Health Pro System be carried out and improvements implemented
- Formal training provided to all new nursing staff on Prison Health Pro System and refresher training to all nursing staff at least annually
- External medical records of any inmate entering custody be made available within 48 hours of request by CPHS
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