Finding into death of Benjamin Elijah Mills
Deceased
Benjamin Elijah Mills
Demographics
31y, male
Date of death
2013-02-08
Finding date
2014-10-15
Cause of death
Hanging
AI-generated summary
Benjamin Mills, a 31-year-old prisoner with depression receiving psychological support, died by hanging in his cell at Barwon Prison. Despite ongoing mental health treatment and plans for transfer to a safer unit, he was able to fashion a ligature from prison materials (a boxing hand-wrap) and attach it to a mop handle left accessible in the laundry area. A key system failure was inadequate control of materials that could be used for self-harm, compounded by lack of night-time cell checks. The coroner found the death was intentional but identified rectifiable system failures: equipment access controls were subsequently tightened, policies on clinical reporting were clarified, and next-of-kin notification procedures were improved. Mental health care provision was appropriate.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Clinical conditions
Contributing factors
- Inadequate control and accountability of cleaning equipment in prison cells
- Lack of night-time cell checks and observation
- Access to makeshift hooks in cell design
- Worsening depression despite treatment
- Delay in finalizing transfer to Hoya Protection Unit
Coroner's recommendations
- Corrections Victoria to amend policies for management of at-risk prisoners to articulate expectations and obligations of clinicians in relation to reporting requirements and use of professional discretion
- Corrections Victoria to embed in policy the practice of removing and disposing of all makeshift hooks in Building Design Review Program-compliant cells
- Ensure cleaning equipment is accounted for at end of each day and used on 'as needs' basis only
- Amend memorandum of understanding with Victoria Police to ensure police advise prison location when next of kin notification is made
Full text
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Source and disclaimer
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