Report by the nsw state Coroner into deaths in custody/police operation
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- Cause of Death A post mortem examination conducted by a forensic pathologist, on 16 April 2004 confirmed the cause of death as “Hanging”. Manner of Death
- Actions of Corrections Staff
- Formal Finding RS died on or about 15 April 2004 when he deliberately hanged himself in his cell at Long Bay Correctional Centre, Sydney.
- That DA died on the 27 th June, 2004, at the Goulburn Correctional Centre, MPU; Cell 5, from poisoning by Doxepin, self administered with the intention of taking his own life.
- 826/04 Inquest into the death of SB on 29 July 2004. Finding given 27 April 2005 at Westmead Coroner’s Court by Magistrate Carl Milovanovich, Deputy State Coroner.
- 888/04 Inquest into the death of AW on 12 August 2004. Finding given 28 September 2005 at Westmead Coroner’s Court by Magistrate Carl Milovanovich, Deputy State Coroner.
- Formal Finding. That AW died on the 12 th August, 2004, at the John Maroney Correctional Centre, Windsor, in the State of New South Wales from Coronary Artery Atherosclerosis.
Brief FactsAfter evening muster on 14 April 2004 RS was locked into cell 16, middle landing, Wing 1 in Hospital Area 2 at Long Bay Gaol. Just before 8 am on 15 April 2004 Corrections Officers were alerted by an inmate performing sweeping tasks that RS had hung himself. Two officers immediately attended, unlocked the cell door and found him hanging from part of a sheet attached to a window hinge. With the assistance of their colleagues they lowered him to the ground and sought medical assistance. However, he was already cold to touch and rigor mortis had set in. Dr V pronounced life extinct 20 minutes later. Police were called and a crime scene established. At the time of his death RS was aged 26. A Nepalese citizen, RS had been studying in Australia for several years. His family in Kathmandu were unaware he had been in custody since 28 August 2002 charged with nine counts of Sexual Assault – Category 3. A friend of his continued to send e-mails to the S family purporting to come from RS himself. Due to the nature of his offence, RS, at his request, was classified as a Protection Limited Association Inmate. He had been placed in Long Bay Hospital Area 2 from 3 July 2003 due to overcrowding. He had been housed in various cells during that time. He had been in cell 16 as the sole occupant for two days prior to his death. On 13 October 2003 he was found guilty as charged. He was due to be sentenced on 22 April 2004. Cause of Death A post mortem examination conducted by a forensic pathologist, on 16 April 2004 confirmed the cause of death as “Hanging”. Manner of Death RS was alone in his cell at the time of his death. Neither a thorough police investigation nor an internal investigation by prison authorities has discovered any evidence that any other person was involved in his death. PM, who occupied the adjoining cell and who spoke to RS on a daily basis, heard RS’s toilet flushing sometime between 9.30 pm and 10 pm on 14 April 2004. Around 10.30 pm he heard banging noises that sounded like a bed knocking against a cell wall. This was the last sound to emanate from cell 16. PM had spoken to RS before lockdown on the afternoon of the 14th and noticed nothing unusual about his demeanour. However, in previous conversations, RS had expressed concern about his forthcoming court appearance. RS did not leave a suicide note. However, in a writing pad he had written a message revealing his despair, “Oh God! If there is a god. Save my soul if I have a soul.” Nevertheless, he had never given any indications of self-harm in the course of his prison assessments. He had been seen on 13 April 2004 by his case officer and the following day by his case supervisor. Neither recorded any issues that were causing him concern.
It was noted that in the wake of RS’s death, strategies have been implemented by Justice Health and the Department of Corrective Services to expedite the movement of prisoners to and from Long Bay Hospital. Such strategies are to be encouraged. It is understood, however, that the placement of unsentenced inmates is dependent on the availability of accommodation facilities within the Remand Centre. The Deputy State Coroner had no criticism of RS’s placement and did not consider it to be a major contributing factor to his decision to end his life. Actions of Corrections Staff It was considered that RS was correctly classified by the Department of Corrective Services. The Deputy State Coroner was also satisfied that he provided no indication of his intentions to staff so that they could have attempted preventive action. It was considered that Corrections staff acted promptly and appropriately when notified of RS’s death. Facilities While detailed evidence was not heard on the aspect of hanging points in cells on this occasion, judicial notice was taken of the fact that it is virtually impossible, even in the most modern correctional facilities, to eliminate hanging points. Formal Finding RS died on or about 15 April 2004 when he deliberately hanged himself in his cell at Long Bay Correctional Centre, Sydney. 687/04 Inquest into the death of DA between 3pm on 26 June and 8am on 27 June 2004. Finding given 5 October 2005 at Goulburn by Magistrate Carl Milovanovich, Deputy State Coroner. Inquest Summary: The deceased was sentenced in 1997 for a number of armed robbery and aggravated sexual assault matters. His total sentence allowed for release on parole in 2008 with final release in 2012.The deceased was classified as E.2 medium security having had one prior escape and had a history of self-harm. In 1999 he was found in his cell following an overdose of Doxepin and was admitted to hospital and survived. The deceased was diagnosed with depression and was taking Efexor up until March, 2004, when his psychiatrist changed his medication back to Doxepin. The deceased kept very much to himself, refused to associate with other prisoners and was considered a quite and a model prisoner. In June of 2004 a decision was made to move the deceased and to encourage him to have greater contact with other inmates. It was noted that he was loosing weight and he was referred to medical staff to address his weight loss. He denied that he was on a hunger strike and refused to see either a psychologist or psychiatrist. The deceased was found deceased in his cell on the morning of the 27th June, 2004, and a subsequent post mortem determined that he had died from Doxepin poisoning. It became apparent from the evidence that the deceased had been hording his Doxepin medication and expert opinion suggested that he would have taken approximately 30 tablets to reach the levels found through toxicology. The deceased had been prescribed 2 x 50 mg tablets of Doxepin daily. When Police searched his cell following his death, a further 20 Doxepin tablets were found secreted in a newspaper. An internal investigation into the death by the Department of Corrections identified a number of issues; they included the failure to detect the drugs through routine cell checks and the fact that the medication should have been administered to the deceased under supervision. It was apparent; despite his earlier suicide attempt that his medication was simply dispensed daily and there was no requirement for the deceased to be supervised to ensure he had consumed the medication. The Inquest was told that since the death of the deceased a memorandum had issued that now requires that all prisoners who have been prescribed anti-depressant medication are to take that medication under supervision. The Inquest was also informed that Corrections Health are in the process of preparing a new Manual in which various drugs will be identified and the manner of dispensation given. Under these circumstances the Coroner was of the view that formal recommendations were not necessary. Formal Finding. That DA died on the 27th June, 2004, at the Goulburn Correctional Centre, MPU; Cell 5, from poisoning by Doxepin, self administered with the intention of taking his own life. 784/04 Inquest into the death of SK on 18 July 2004. Finding given 17 August 2005 at Westmead Coroner’s Court by Magistrate Carl Milovanovich, Deputy State Coroner. Inquest Summary: The deceased was questioned at a residence in Sydney following the lawful execution of a Search Warrant pursuant to Section 251(4) of the Migration Act, 1958. The deceased was suspected of being an unlawful resident as he was not able to verify his identity. He was not detained pursuant to Section 189 of the Migration Act, 1958, although evidence did suggest that he was an unlawful resident. A decision was made to convey the deceased to an address he nominated at which the deceased maintained he had proof of his identity and residence status. While being escorted from the premises and being directed towards a van, with an open door, the deceased commenced to run. A direction was given to “grab him”, however, within a matter of seconds he had run to the road edge, appears to have stumbled and fallen into the path of a moving vehicle. He died in hospital for head injuries some 3 days later. While the Coroner assumed jurisdiction under the provisions of Section 12 of the Coroners Act, it was also a matter that prima facie fell under the provisions of Section 13A of the Coroners Act and in fact was treated as a 13A death by the Coroner on the information that was provided at the time the death was reported. After examining the evidence at Inquest the Coroner was of the view that on the balance of probabilities the deceased was in lawful custody and that he in fact was attempting to escape from lawful custody at the time he received the injuries that led to his death. A number of issues where identified during the Inquest in relation to the training of DIMIA staff, the protocols for consulting with State police in regard to operational matters and the desirability of DIMIA staff to be aware of the provisions of State Laws that may impact on their duties. No formal recommendations were made, however, the Coroner did direct that the brief of evidence be forwarded to the Minister responsible for DIMIA. The Coroner found that the death of the deceased was accidental; no fault could be attributed to the driver of the vehicle or the DIMIA staff. Formal Finding: That SK died on the 18th July, 2004, at Westmead Hospital, Westmead in the State of New South Wales, from a head injury, sustained on the 15th July, 2004, when he fell and was struck by a motor vehicle, outside 15 Leicester Avenue, Strathfield in the State of New South Wales. 826/04 Inquest into the death of SB on 29 July 2004. Finding given 27 April 2005 at Westmead Coroner’s Court by Magistrate Carl Milovanovich, Deputy State Coroner. Inquest Summary: The deceased had a history of medical and mental problems and consumed alcohol. There was a history of prior incidents of self-harm, he had recently lost him employment and was facing drink-driving charges at Court. On the day of his death he left a note on a white board in his home which contained, amongst other things the words “I love you all, bye”. At about 1.00pm on the 29th July, 2004, Police responded to a concern for welfare in regard to a male person who was standing on top of the Knapsack Gully Railway overpass at Lapstone. Sgt R was the first Police to attend the scene and observed the deceased on top of the bridge. He spoke to the deceased to the affect of requesting him to come down, however, without response the deceased stood up, placed him arms outward and leaped from the bridge. He fell a distance of some 50 metres and suffered fatal injuries and was pronounced deceased by Ambulance personnel at the scene shortly after his fall. The death was treated as a Section 13A death on the basis that the Police were present and had conversation with the deceased. The deceased had also been reported as a missing person earlier in the day. All necessary critical incident protocols were followed and the family of the deceased expressed no concerns in regard to Police involvement or the investigation. The deceased family did not attend the mandatory inquest. Formal Finding: That SB died on the 29th July, 2004, at Knapsack Gully, Lapstone in the State of NSW, from chest and abdominal injuries, self-inflicted with the intention of taking his own life when he jumped from the Knapsack Gully Rail Overpass. 888/04 Inquest into the death of AW on 12 August 2004. Finding given 28 September 2005 at Westmead Coroner’s Court by Magistrate Carl Milovanovich, Deputy State Coroner. Inquest Summary: The deceased was serving a 15 year sentence for Murder, he was due for release in 2011 and was aged 73 at the time of his death. The deceased had been diagnosed with coronary artery disease while an inmate at Cessnock Correctional Centre and it was recommended that he should undergo by-pass surgery, which he declined. The deceased was being medicated with aspirin and metoprolol daily and when last seen by a medical practitioner on the 6th July, 2004, it was recommended that he be taken off the metoprolol due to a skin rash. The treating medical practitioner recommended that the deceased should have daily blood pressure check conducted. It appears that notation in the medical records was not followed up. The post mortem examination determined that the deceased had severe artery disease with stenosis of up to 30%. The failure to take blood pressure readings did not directly cause his death. The Coroner requested that Justice Health who sought leave to appear at the Inquest ensure that recommendations made by locum medical practitioners are followed up and reviewed if necessary. No formal recommendation was made. The deceased, on the date of his death was observed to be holding his chest and complaining of chest pains. He collapsed shortly after, was still breathing and was placed in the recovery position while medical assistance was sought. He had passed away before Ambulance and Paramedic staff arrived. Formal Finding. That AW died on the 12th August, 2004, at the John Maroney Correctional Centre, Windsor, in the State of New South Wales from Coronary Artery Atherosclerosis. 919/04 Inquest into the death of AH on 7 May 2004. Finding given 14 July 2005 at East Maitland by Magistrate Dorelle Pinch, Deputy State Coroner. Directory: Documents Documents -> Concept stage Documents -> Concept stage Documents -> The great global switch-off Documents -> Nonprofit grant application Documents -> The Truth about the Rwandan Genocide Documents -> Annual InStructional unit plan Documents -> Chaos equipment included Download 0.8 Mb. Share with your friends:
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