Inquest into the death of Michael Black

33y · Male·stab wound to the chest

Michael Black, a 33-year-old First Nations man, died from a stab wound to the chest while detained at Parklea Correctional Centre on 22 April 2020. He was stabbed by fellow inmate Emmett Sheard in a crowded holding cell during a dispute over diverted Suboxone medication. Critical failures contributed to this death: (1) Sheard had been released from segregation prematurely on 31 January 2020 without referral to the High Security Inmate Management Committee despite a recent serious stabbing and extensive violence history; (2) inmates were not searched before placement in holding cell 4, allowing weapons into the cell; (3) 18 inmates were overcrowded in a 5×3 metre cell creating a volatile environment; (4) CCTV camera coverage of the cell was not actively monitored and remained covered for 40 minutes; (5) Michael had requested assessment for opioid substitution therapy since reception on 28 February but had not been assessed by 22 April, contributing to his desperation for diverted medication. Systemic failures in risk assessment, searching procedures, cell management, and healthcare delivery created conditions enabling this preventable death.