Coroner hands down findings in Frederick Row Row, 34, death in Capricornia Correctional Centre case

A coroner has handed down findings into death in custody of an inmate at Capricornia Correctional Centre five years ago.

The family of a proud Darumbal and Kullilli man who died by suicide, captured on CCTV, after he told psychological staff he considered taking his own life, will have none of their recommendations to an inquest actioned.

Frederick Row Row, 34, died by suicide at Capricornia Correctional Centre late in the morning of August 24, 2016.

In the past 17 years there have been 18 inmate deaths at the Capricornia Correction Centre.

An inquest into Mr Row Row’s death was held at Yeppoon Magistrates Court on March 10, 2020 and May 17-18, 2021, with written submissions sent in June 2021.

Issues surrounding the response to Mr Row Row’s mental health issues, prison protocols particularly around the door to the exercise yard being left open for 10 years, along with the staff roster system for corrections services and mental health staff were considered as part of the inquest.

State Coroner Terry Ryan handed down his findings Tuesday morning in Brisbane, with a copy of his findings provided to this publication after he delivered them in court.

The family told News Corp they felt like Mr Row Row was “treated like he was nothing”.

His sister Pam White-Row Row said she was “disgusted” at the findings due to the lack of mental health support offered to Indigenous prisoners.

Family of Frederick Row Row (L to R) his partner Glenda Barnes, sister Pam White-Row Row, daughters Sheanea Row Row and nephew Dennis Saunders walk out of the Coroner's Court in Brisbane. The coroner delivered his findings into the death of Indigenous man Frederick Row Row, who died in custody in August 2016 Picture: NCA NewsWire / Dan Peled

“I felt not heard … I felt my brother was treated like he was nothing … (we’ve been) waiting for five years to get told nothing,” she said.

“What I was looking for at these findings was I wanted more mental health support for all prisoners, to be able to contact family for support.

“And nothing’s going to change in prisons.”

Mr Ryan’s findings report highlighted the four recommendations made by Mr Row Row’s family members, which included targeted recruitment for male psychologists that were more culturally appropriate for First Nations prisoners; more and better cultural awareness training for staff; more and better training around risk assessment, especially for the issues unique to First Nations prisoners, for those staff involved in risk assessment teams; and more funding to improve psychological and mental health services within correctional centres and allowing community-based providers access to the centre to enhance service delivery.

In the lead up to Mr Row Row’s death, he told his partner over the phone he believed several inmates were ‘eyeballing’ him.

Frederick Row Row's sister Pam White-Row Row (right) and his daughter Sheanea Row Row stand for a photo outside the Coroner's Court in Brisbane. The coroner delivered his findings into the death of Indigenous man Frederick Row Row, who died in custody in August 2016, Picture: NCA NewsWire / Dan Peled

After the call, he had a fight with another inmate, telling staff he had a ‘brain explosion’ when he punched the inmate several times in the head.

The inmate ended up with a fractured skull and a bleed on the brain.

Mr Row Row was removed from his unit as a result and fearing the inmate would not live, he stated he was going to take his own life because he had killed the inmate.

He also said because there had been so many deaths in his family, he wanted to die too.

At 6.22pm on August 21, the day of the fight, Mr Row Row was assessed as being of ‘high risk’ of self-harm and was taken to the medical unit, placed in an at-risk cell, on a 15 minute physical / 15 minute CCTV observation regime.

He was assessed the next day by a provisional psychologist, while wearing a prison-issued suicide gown, and cited stressors including his partner’s sister’s death, a suicide by a close family member six days earlier, his mother’s death in 2015, the conditions of his Intensive Management Plan and a warrant for his daughter’s arrest.

Mr Row Row said he felt a great deal of shame over the assault, which was exacerbated by his cultural position within the centre as an older First Nations male.

The psychologist told the inquest she took into consideration what Mr Row Row, along with cultural information from the Cultural Liaison Officer (CLO), said.

She stated Mr Row Row was open to assistance and denied any suicidal ideation, plan or intent.

She reduced his at risk level from high to medium, which required 60 minute physical and 60 minute CCTV observations.

Mr Row Row was assessed the next day, by a different psychologist and CLO, where he expressed more concern for the other prisoner’s health than his own, and raised concerns and issues relating to his daughter and recent deaths in the family.

This psychologist told the inquest he had know Mr Row Row for about 10 years, and based his risk assessment on Mr Row Row’s responses to a list of questions and his body language.

A Darumbal woman who has worked in the justice system told investigators after Mr Row Row’s death that she had told Mr Row Row the other inmate was alright and off the life support machine, as the inmate’s family had called her with updates.

At a Risk Assessment Team meeting on August 23, the CLO there advised a third psychologist and a supervisor he recommended Mr Row Row’s observations be reduced to low.

The supervisor, who was the correctional supervisor for the prison’s health unit, interviewed Mr Row Row for the RAT meeting.

This supervisor told the inquest he used the risk matrix but did not have training in risk assessment.

He said that he ‘just wrote down the answers’ and referred to recent case notes on IOMS.

The RAT ultimately determined that observations could be reduced to two hourly physical observations in appropriate accommodation, which led to Mr Row Row being moved from the health unit to the detention unit about 3pm.

He was found crying in the cell at 7.30am the next day and asked if he could speak to the CLO.

A psychologist was arranged to meet with him out of concern for his welfare and that psychologist waited until a CLO commenced work before speaking with Mr Row Row at 8.20am.

An hour later, Mr Row Row was handed a phone and the internal door to the exercise yard was opened for him so he could call his partner Glenda Barnes.

The call was abruptly cut off due to time expiring at 9.58 minutes. During the phone call Mr Row Row was audibly upset.

He was crying and told Ms Barnes of his concerns about the other inmate’s condition and raised concerns if the inmate died, he would get a life sentence.

It was the last time he and Ms Barnes spoke.

Mr Row Row then asked if he could make another call, but he was not allowed.

Throughout the morning, Mr Row Row had five interactions with a corrective services staff member with the last sighting recorded at 11.30am.

Eight minutes later, Mr Row Row was found deceased from suicide.

Mr Ryan referred his findings to the existing Closing the Gap partnership but made no further recommendations.