Inquest into the Death of Bradley James Savory

Contributing factors

• Gambling debts accrued through illicit prison betting systems
• Financial difficulties and inability to repay debts
• Low self-esteem and negative self-image prior to incarceration
• Distress about the crime for which he was imprisoned
• Perception of lack of family support and belief family did not appreciate his achievements
• Difficulty maintaining control over his life and sense of futility
• Inability to obtain requested $300 from friend on evening before death
• Masking of true emotional state from those around him

Coroner's recommendations

1. Prison authorities should encourage families with concerns about relatives in prison to report those concerns without fear of reprisals, with assurance that the situation will be handled sensitively
2. Methods should be found to assess and verify explanations for large unexplained sums of money received by prisoners' accounts (over $40 threshold)
3. Medical files should be complete and include all prior self-harm attempts and medical incidents to enable proper assessment of prisoner risk
4. External information sources may be necessary to detect sophisticated gambling and debt systems in prisons
5. Policies restricting canteen goods holding should be maintained and monitored, though prisoners can circumvent by distributing goods among multiple individuals