Death in custody inquest: Prison door left open for 10 years

A door leading out to the prison’s exercise yard, which had been left open under local protocols for 10 years, was a key issue raised in a death in custody inquest after an inmate died by suicide.

A door leading from a prison’s detention unit to the exercise yard which had been left open under local protocols for 10 years was a key issue examined in a death in custody inquest where an inmate died by hanging himself.

Evidence was presented to the Coroner Terry Ryan in Yeppoon Magistrates Court on Tuesday, May 18, for the inquest into the death of Capricornia Correctional Centre inmate Frederick Arthur James Row Row, who died after being held in the Detention Unit for days following his assault on another prison.

Mr Row Row died on August 24, 2016, after requesting to be relocated to the prison’s Medical Unit.

The inquest heard from Capricornia Correctional Centre general manager Alexis Livingstone, Queensland Corrective Services Assistant Commissioner Peter Shaddock, as well as psychologist and expert in suicide prevention - particularly vulnerable populations such as the Aboriginal community - Dr Samara McPhedran.

Ms Livingstone, who has worked in corrections for 20 years of which 14 were in management roles, told the inquest the door from the Detention Unit, which had 10 cells and one QCS officer rostered to it on 12-hour shifts in 2016, to the exercise yard, was left open under local practice, but she was not aware of this until after Mr Row Row’s death.

The court heard this should not have been the case, according to statewide protocols.

The one officer rostered to the Detention Centre also had responsibilities which took them outside the unit, including dealing with the food trolley.

Ms Livingstone said after Mr Row Row’s death, she had signage placed and centre-wide emails sent for all staff to be aware of the change in local protocol.

The inquest heard in the months prior to Mr Row Row’s death, his parole release date had changed from April to December, he assaulted a QCS officer, his close friend died of natural causes while incarcerated and Mr Row Row assaulted a fellow inmate.

He had been assessed by the prison’s Risk Assessment Team, which included a psychologist, a cultural liaison officer, the inmates supervisor, and other prison staff.

When he first went into the Detention Unit on August 21, 2016, he was deemed a high risk, but that was dropped to medium risk the following day.

But by the morning of his death, he was seen crying and requested to be moved to the Medical Unit.

Dr McPhedren said according to the information available, Mr Row Row had openly admitted to suicidal thoughts on August 24.

She said prison psychologists had only recorded his verbal responses on the previous days and it was well documented people did not always disclose they were having suicidal thoughts.

Dr McPhedren said one contributing factor overlooked was Mr Row Row’s impulsivity, which led to his thoughts changing to action in a very short time.

“Aboriginal people may be more impulsive and have fewer warning signs,” she said.

“Mr Row Row had a history of impulsivity with regards to aggression.”

Ms Livingstone said Mr Row Row “was an influential prisoner” within the Indigenous community and had a strong network of men in the prison, based on the information she had obtained from her staff.

“I was aware Mr Row Row was involved in a number of incidents at Capricornia Correctional Centre,” she said.

Dr McPhedren raised concerns with the lack of continuity for treatment of prisoners with mental health issues at the prison, lack of noting physical signs of suicidal ideation, the lack of observing Mr Row Row more regularly after he reported the suicidal thoughts, lack of communication between psychologists and cultural liaison officers about Mr Row Row assessments, identifying feelings of shame as an important motivation for suicide, sleep disruption, along with absence of positive future outlook by Mr Row Row.

Legal parties involved in the inquest will now put written submissions to the coroner.

Originally published as Death in custody inquest: Prison door left open for 10 years