Inquest finds Joshua Kerr’s death in Victorian prison a ‘preventable tragedy’

A Victorian coroner has ruled the death of Indigenous man Joshua Kerr at Port Phillip Prison was preventable and that security concerns were placed above the prisoner’s medical needs.

Joshua Kerr died in custody in August 2022.

A Victorian coroner has ruled the death of Indigenous man Joshua Kerr at Port Phillip Prison was preventable and that security concerns were placed above the prisoner’s medical needs.

In an hour-long hearing to a courtroom packed with family members and members of the Aboriginal community, coroner David Ryan on Monday said there were several occasions when more effective action could have probably prevented the 32-year-old man’s death, caused by ice toxicity, on August 10, 2022.

At 9.16am on the morning of the fatal tragedy, Kerr lit a fire inside his cell by inserting a metal strip from a face mask into a power socket.

He told a nurse during a psychiatric assessment that he was paranoid from using ice and that he did not intend to take his life by lighting the fire, but that he wished he had died.

Kerr was transferred to St Vincent’s Hospital in Melbourne to treat his burns and arrived at 12.20pm. Triage notes recorded he had “smoked and snorted” ice before lighting the fire.

At 1.20pm, the plastics registrar decided he did not need to be admitted to hospital for his burns, but Kerr was frustrated after waiting for his hand to be treated and said he wanted to return to the prison.

Port Phillip Prison, which is privately operated, will close at the end of 2025. Inmates will be transferred to the government-operated Western Plains Prison in Lara.

He pulled out a cannula which had been inserted in his arm, refused a Covid test and became aggressive and abusive to staff.

At around 2.49pm, TOG (Tactical Operations Group) officers cancelled the escort and took him back to prison before he was formally discharged.

Kerr was placed in the prison’s St Johns unit at 4.43pm, but medical staff had not been advised the escort to the hospital had been cancelled and his discharge summary was not available to them.

At 5pm, his cell was shut and correctional staff were given a directive that his cell could not be opened without the presence of TOG officers.

His behaviour became increasingly bizarre and erratic, including taking off his clothes and removing his bandages, which was observed by prison staff through CCTV and the window of the cell. At 6.40pm, TOG officers and medical staff spoke outside Kerr’s cell about administering medication to him, but a decision was made to “wait for him to settle” before treating him.

From 7.40pm, Kerr’s movements became slower and he struggled to stand.

The last movement seen from Kerr was at 8.01pm and at 8.10pm, a “code black” was called, but Kerr’s door was not opened due to the directive.

At 8.18pm, medical staff gave CPR to Kerr and called an ambulance but he was pronounced dead at 8.41pm.

There was a delay of 16 minutes between Josh becoming unresponsive and him getting medical treatment.

Coroner Ryan said TOG officers should not have cancelled their escort and that at 6.40pm the medical team could have applied the Acute Poisoning Management Guideline and called an ambulance.

The Coroner handed down seven recommendations, including that prison medical staff receive training.

Kerr’s mother, Aunty Donnas Kerr, said there was a lack of care and compassion for Aboriginal lives in the prison system. “For hours they didn’t go into his cell or call an ambulance,” she said.