The Deputy State Coroner is recommending an overhaul of the way in which Goulburn Supermax prisoners with mental illnesses are treated.
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Theresa O’Sullivan also wants a review of whether there are enough mental health beds available in the NSW correctional system to meet demand.
These were just some of 11 recommendations handed down into the death of Junior Fenika, 24, in Goulburn jail’s high risk management unit on September 12, 2015.
Ms O’Sullivan found his death was preventable. Fenika took his own life in a Supermax cell. Before he died, he twice called an officer through an intercom system.
“If Corrective Services officers had responded appropriately to the intercom calls, it is likely that he would have received medical treatment and his death would have been prevented,” Ms O’Sullivan said.
The calls at 9.17pm and 9.23pm on September 11, 2015 advising the officer that he had self-harmed, were misunderstood, partly due to intercom audio quality. Ms O’Sullivan said this officer should have “reverse called” Fenika to clarify what he was asking. If this had been done, an ambulance would have been called and assistance rendered, she said.
An accident and emergency specialist, Dr John Vinen, told the inquest it was likely that Fenika was still alive at 2am, based on CCTV footage of the cell’s rear yard.
The officer had however informed two roving colleagues of Fenika’s calls. Both were in the meal room at the time they were asked to check on the inmate.
“Both had already eaten. The first round of the national rugby league finals was on that night and the game was likely to have been concluding about the time of (the officer’s) call,” Ms O’Sullivan said.
But in evidence, neither officer could recall watching the football.
The roving officers on this shift were not authorised to have cell keys. They undertook a visual inspection of the cell door, smelt and listened in the area but noticed nothing unusual.
But Ms O’Sullivan said the officers should have used an intercom to communicate with Fenika.
“It was a clear failure by two officers and it is deserving of censure,” she said.
“It is likely that if the call had been made that Junior would have told them he had (self-harmed) and they could then have taken immediate action, including informing the night senior and asking for an ambulance to be called.”
Later, at 10.52pm, two other roving officers walked through a mix of blood and water running from the rear of Fenika’s cell. They noted nothing unusual, though Ms O’Sullivan said they were more focused on looking for unlocked yard gates or obvious signs of escape.
Fenika was found dead in his cell at 8.30am the next day, 18 and a half hours after he was locked in. She found he died from “massive blood loss caused by incised wounds of the left upper extremity.”
Ms O’Sullivan recommended changes to night watch procedures, including visual checks on welfare, improvements in intercom audio quality and checking protocols. She also recommended consultation with Justice Health on whether Supermax inmates who had recently engaged in or threatened self-harm should have access to to razors and other sharp objects.
Prisons’ mental health ‘bed shortage’
The inquest heard that Fenika had been become more stressed after his visa was cancelled in January, 2015. He was kept in Supermax beyond his sentence’s expiry in August, 2015, pending deportation to New Zealand.
Two psychiatrists agreed Fenika was suffering schizophrenia and psychoses at the time of his death and that placing him in isolation had “precipitated and amplified his mental illness.”
A total 117 mental health prison beds are available at Silverwater and Long Bay. The psychiatrists said demand was far higher than available beds. One said if the number were double or tripled, they would be “easily filled.” Ms O’Sullivan recommended a review of their adequacy, that Corrective Services give Justice Health “real time” information about Supermax inmates in isolation, appropriate access and tele-health facilities.
The inquest heard a treating psychologist at Goulburn understood Supermax prisoners could not be transferred to prisons with mental health beds, given the security risks. However, Corrective Services said this was not a policy. Nevertheless, it meant that no application was made to transfer Fenika.
Ms O’Sullivan recommended that sufficient security be provided to allow transfer of Supermax inmates to Silverwater’s mental health screening unit for treatment. Further, where a psychiatrist had found that segregation or isolation was adversely affecting an inmate’s mental health, this should be brought to the attention of the unit’s general manager.
Corrective Services responds
Corrective Services declined to say specifically whether it accepted the inquest’s findings or what recommendations it would implement.
“Corrective Services NSW deeply regrets the death of Mr (Fenika) and has extended its deepest sympathy to his family,” a spokeswoman said in a statement.
“Every death in custody is a tragedy and we know that it can be a very traumatic experience for the family.
“We supported the coronial investigation and have co-operated fully with the Coroner.”
The spokeswoman said the department was reviewing the Coroner’s findings and if there were policies that need to be changed, it accepted this.
“The CSNSW Management of Deaths in Custody Committee considers and oversees the implementation of coronial recommendations,” she said.
“The committee is chaired by an Assistant Commissioner and comprises senior executives from CSNSW, Justice Health and Forensic Mental Health Network and a representative from the NSW Police Force. A representative from the NSW Coroner’s Court is also invited to attend meetings as an observer.”
Corrective Services did not answer questions on whether it had plans to boost the number of mental health beds.