Police will never accept deaths-in-custody recommendations

by ray jackson, president, indigenous social justice association

Why are deaths in custody rising? a very good article from ms. inga ting on the abject and sorry state of the national gaol systems and the horrific number of deaths in custody but especially nsw.

whilst pm howard shut down the legal requirement for the governments of the states and territories and their appropriate departments in 1998 because, according to him, the allocated $400 million had been spent. some of this money was spent on building new police stations, the macquarie fields station being but one example.
when it was opened i and some others were invited to come and see their jewel in the police crown. what they wanted was for us to be photographed outside the new station and giving it the rciadic tick of approval. they got the photo opportunity but not the approval.

this was a million dollar plus use of the dic/rciadic monies and they spent up big. carpeted throughout, huge fishtanks, whilst muzak also wafted sweet music through the building. what the station also contained was 4, yes, 4 only concrete boxes with bars. no carpets, no fish, no music and no heating or cooling. the cells contained the obligatory hanging points. most certainly r165 was totally ignored. the cells also contained the recommended cameras but they were placed, perhaps purposely, to take in the full view of the shower and toilet in each cell. when this was pointed out to the el supremo of the station, along with the hanging points, the dismissive reply was that all the officers were specially trained to monitor the cells vis-a-vis the hanging points but to ignore the shower and the toilets when necessary.

we were never invited back and ms phyllis may was found hung in june 1992. the police, nationally, still continue to totally ignore the recommendations.

but as gerry georgatos has pointed out our nations' gaols are defaulting badly and are echoing the bad old days pre-rciadic. why is the gaol rate of dic rising so dramatically? it is, of course, not just because of the numbers although this is an important factor. the main reason i believe is the ratio of officers to inmates being dangerously reduced, but still not as bad as the private gaols, but the nsw commissioner and minister are actively working on it.

knowing ex- senior assistant commissioner, catriona mccomish, i read with great interest her views of the important introduced programmes then being destroyed when it no longer suited the commissioner due to its costs and no longer being of interest to the security needs of the commissioner. programmes have steadily been downgraded to the end that working for corrective services industries is more favoured as a possible rehabilitative process. it seems that education, life skills, etc. are no longer the requisite to help inmates not to be a recidivism statistic, better to make dollars for the system.

the custodial systems need to return to the rciadic recommendations to provide life saving procedures for all.

there are far too many people in the nsw gaols but they, the gaols, are at the bottom of the heap. they must take what is sent to them. their job, their duty of care, is to keep inmates alive long enough to be able to rehabilitate them. we know, and they know, that they are failing and failing miserably. instead of continuing to expand the nsw commissioner's empire with the same failed system he needs to properly ensure that the 61 recommendations are properly implemented. especially r122 re duty of care and r165 re the removal of evident hanging points. if corrective services were a private company rather than a government one funded on taxpayers dollars they would have been shut down years ago for failing to live up to their charter and mission statement.

they would also have been done for false advertising for not living up to their hype. but as i said they are at the tail-end of the process.

the second level that is ignoring the recommendations and also failing badly is the nsw courts, including juvenile justice and the coroners courts, and the judiciary. the courts have 29 recommendations. perhaps the most important recommendation is r92 that calls for incarceration as a matter of last resort. this should be easier than it looks but with the avid input of the police and dpp's, it is not. i would really like for a statistician to look at court trials, including juvenile justice, say from 1/1/2000 to 1/12/2010 and compile three sets of figures. firstly the overall statistics of the number of times police/dpp opposed bail thus getting a person sent to gaol. then to break the figures down to aboriginal and -non-aboriginal. i would argue that there would be a statiscally larger number of opposition to bail for both aboriginal adults and youth than for non-aboriginal adults and youths. just a hunch but i reckon i'm right.

that only leaves the snakes head, the police. the police, as i keep repeating, has never and will never accept the recommendations as being any part of their responsibilities. as a nsw deputy commissioner told me quite forcefully, inter alia, the recommendations are not for us, they are for the politicians, our job is to catch criminals and protect the public. and that view remains rock-solid across australia.

so where does that leave us individuals calling, and protesting, for justice? right out in the bloody cold! regardless of the tragedies born from such an arrogant, racist and unfeeling attitudes, the police force still power on protecting, not the poor and the vulnerable, but their own and the governments/establishment.

the royal commissioners themselves clearly recognised the social unattractiveness of the history of police malpractices and allocated no less than 99 recommendations in a vain attempt to humanise them and their corrupt work methods. of the 99, or some 34.1% of the 338 recommendations accepted by the hawke government in 1991, must be fully and firmly instituted to make the whole system of recommended changes work to the benefit of all and not for just some. some of the most important recommendations are:

r35 a to e/36. investigations should be approached on the basis that the death may be a homicide. suicide should never be presumed ( this applies to police investigations of deaths in gaols, juvenile centres or courts). matters of investigation should include general care, treatment and supervision of the deceased prior to death. along with other pertinent investigative matters. .

r41 that all dic be reported to the coroner and to the australian institute of criminality for statistical purposes.

r60 that violent or rough treatment or verbal or racist abuse of aboriginal detainees, including women and youth be monitored and cease as a practice. such treatment must be identified as disciplinary breaches and dealt with as such.

r81/85 that police arrest for drunkenness include alternative options of taking the person home or to a proclaimed place such as a sobering-up centre.

r86 that offensive and racist language by police cease.

r87a that arrest be as a matter of last resort.

r90 that bail be considered whenever possible.

r94 that community service orders be accepted as a serious option. that such cso options include personal development courses.

r122 that all custodial officers recognise their legal duty of care to those in their custody.

123 that all custodial areas establish clear policies for breaches of departmental instructions.

r125/126 screening forms to be completed on arrest and again in incarceration.

127a-f i-ix that proper medical services to persons in police custody be given.

r133 that all police, at all levels, be trained to properly evaluate detainees in distress.

r134 that police instructions require that at all times police interact with detainees in a humane and courteous manner.

r137 that upon arrest and/or incarceration police or prison officers monitor their detainees/inmates for the first 2 hours by checking them at least every 15 minutes and thereafter at least every hour.

r140 that all police cells be fitted with an alarm intercom systems, similar to gaol cells.

r144 that wherever an aboriginal person is put into a cell, where possible he go in with another aborigine.

r159/160 that police stations and gaols have readily available resuscitation equipment of the highest quality.

r177 that those custodial officers with blatant racist views be not employed.

r226 a-k that complaint procedures against police be urgently reviewed and updated as required.

r239/240 that police proceed, when dealing with juveniles, with the use of formal or informal cautions or a court attendance notice rather than arrest.

r242/243 that juveniles not spend extended hours in a police cell.

i realise that i have gone on a bit, as they say, but i have tried to show the broad scope of recommendations that would allow for positive change with the police methods if only our weak-kneed governments would force the cops, under pain of dismissal, to properly and fully implement all 99 recommendations appertaining to their area.

i believe that i have clearly shown the way to stop the increase in incarceration numbers, along with the subsequent decrease in dic numbers. by fixing the systems for atsi peoples the positive flow-on effects would also work for the non-atsi peoples as well.

after 20 years it is proven beyond a doubt that if and when the police accept their duty of care responsibilities then something positive would be possible for the courts and the gaols and juvenile justice and the raison detre for the recommendations would be allowed to work without prejudice.



It's no secret to anyone who's ever had any involvement with law enforcement
that men tend to take statute as guidelines to be worked around when
circumstances allow while women tend to work within the law. So why is all
this commentary on deaths in custody so starkly discriminatory against the
circumstance of women, who comprise around ten per cent of indigenous deaths
in custody and a considerable proportion of law enforcement, apart from the
occasional example convenient to conversation. If there's a single reason
why deaths in custody are increasing look no further than the intransigence
of this discrimination. Men's deaths in custody watch committees and their
equivalent alone have failed. It's long past time to convene women's deaths
in custody committees to take sole responsibility over concerns for the
deaths of indigenous women, to set an example for the way forward as women
did with indigenous legal services in Redfern several years ago, since
undermined under the choke of paternalism. More of the same is not an
option. For exactly the same reason the US Congress passed fair inclusion
laws to increase the representation of women in the finance industry as a
safeguard against a further global economic crisis, deaths in custody watch
committees urgently require autonomous women's representation. Only then
will the raison d'etre for the recommendations "be allowed to work without


What actual evidence are you relying on in your statement that none of the recommendations have been implemented by the NSW Police?

If you look into relatively recent changes in NSW such as the Law Enforcement (Powers and Responsibilities) Act in NSW, you will see that arrest is already a last resort (r87a)...

Aboriginal people in NSWP custody are allowed an interview friend and/or support person when in custody (r144)

Screening forms are completed when any person comes into Police custody (r125)

Juveniles in NSW that can be identified are, by virtue of the Young Offenders Act, dealt with firstly by informal means (caution / conference) - court appearance is a last resort. (r239)

look at the Bail Act - (r90) I think you will find that bail is already pretty liberally applied.

I won't go on, but I believe that more attention needs to be given to the question: Why is it that Aboriginal people are more likely to come under the notice of police? Is it that they commit more crime? Is it that they tend to commit crime that is more detectable (street offences, drunken behaviour)? Is it that they are being given more police attention than other parts of the community? If so, why?

How about we attack the problem at it's root rather than try and make the system cope with the imbalance.

ray jackson, president, indigenous social justice association

Subject: the ryan and walmsley dic

the second in a series of articles by ms. inga ting on deaths in custody issues.

the deaths of ms. larna ryan at bathurst gaol in 2005 and desmond walmsley at the long bay gaol complex in 2007. both deaths were by hanging. so much for r165 that calls for the removal of all evident hanging points in cells back in 1991.

the complete lack of duty of care by both justice health and corrective services is there for all to see. in this technological age of scanners and 'white-mans-magic boxes' it is absolutely unnecessary for medical and psychiatric inmate details not to be accessed for screening purposes.

where oh where is their duty of care - r122.

2. Deaths in custody: medical warnings on suicide risk weren't delivered

Inga Ting, freelance journalist and Australian Centre for Independent Journalism associate, writes:
The hanging death of Aboriginal inmate Larna Louise Ryan could have been avoided had prison and health authorities simply checked her medical and case history. There, according to the coroner who investigated her death, staff would have found a "plethora of information" warning that Ryan was a serious suicide risk. Yet despite years of recommendations, policies and procedures urging staff to check prisoner files when conducting assessments, the documents lay untouched until far too late.

Coroners have uncovered inadequate assessment and screening practices at more than 20 inquests into deaths in NSW prison custody in the past nine years, as Crikey began to detail last week as part of a special investigation. Formal recommendations urging government agencies to improve assessment procedures and enforce strict screening protocols were made in 2002, 2003, 2004 and 2006. Yet despite these recommendations, inadequate screening and assessment practices again were identified as contributing factors in two deaths in 2009.

Ryan died at Bathurst Correctional Centre in March 2005. Her last days alive paint a picture of bureaucratic incompetence, at best, or negligence, at worst. No stranger to the prison system, Ryan had a long history of self harm, including two previous suicide attempts while in custody, and multiple psychiatric illnesses, including drug addiction and depression. According to department records examined at the 2007 inquest, Justice Health staff had triggered emergency protocols 24 times during her previous periods of incarceration, when Ryan was identified as being at risk of self harm or suicide.

Refused bail after her arrest for dishonesty offences, Ryan repeatedly warned her family that she would not be able to handle being in prison and would kill herself before returning to custody. Ryan’s aunt, Tina Bonham, said at the inquest she relayed this information to Justice Health staff, but files contained no record of the conversation.

Five days later, Ryan was dead.

Deputy state coroner Carl Milovanovich found prison and health authorities had failed to identify the grave risk to Ryan’s safe custody.

"The death of Larna Ryan in my view could have been avoided ... if it was determined, having regard to all the information that was available, that there was a risk of her self-harming," Milanovich wrote in his findings. "[T]he question that must be asked is why did Correctional and Justice Health staff not access the plethora of information that was available in regard to Ms Ryan’s previous history."

Authorities twice breached Recommendation 126 of the Royal Commission into Aboriginal Deaths in Custody, which states: "That in every case of a person being taken into custody ... a screening form should be completed and a risk assessment made ... [T]he screening form should be completed with care and thoroughness." The inquest found no evidence that Corrective Services staff assessed Ryan on arrival at Bathurst jail, either when she was first remanded or when she returned after a later court appearance.

Records indicate that Ryan was assessed by Justice Health staff, but these assessments were incomplete as staff failed to "obtain a comprehensive medical history for the prisoner including medical records from a previous occasion of imprisonment", as required by Recommendation 157. This failure became clear at inquest, when Justice Health presented the findings of its own investigation into the death, which revealed Ryan’s medical and case files did not arrive until after her death.

The absence of these files was a second breach of Recommendation 157, which also states: "That prisoner's medical history files [should] accompany the prisoner on transfer to other institutions and upon re-admission." Milovanovich was frank in his analysis: "I fail to see any reason in this day and age why medical records cannot be sent by courier -- even over a weekend -- from the Sydney record base to any place in NSW where an inmate is received."

The Royal Commission was unequivocal about the importance of a prisoner’s medical and case history. In its final report, Commissioner Elliot Johnston wrote: "The adequate assessment of a prisoner is highly dependent upon the information available at the time of assessment ... Ambiguous signs may take on a clearer significance if placed in the context of a history of medical or psychiatric illness. Access to a prisoner's medical history records, both from the prison medical service and from outside health agencies would, therefore, be of potentially enormous benefit at the time of assessment."

Milovanovich did not make formal recommendations at the inquest into Ryan’s death, noting that the issue of ensuring an inmate’s medical files were accessed "has already been subject to either formal recommendations or comment by coroners and there is now a standing direction that medical records must be accessed immediately".

Yet 15 days after these findings were handed down, another inmate who had also previously attempted suicide and was known in the prison system as being "a high chronic risk of self harm" hanged himself at Long Bay Correctional Centre. In a disturbing echo of Ryan’s case, the inquest into his death revealed that his family, like Ryan’s, had also made efforts to warn Corrective Services and Justice Health staff that he was planning to kill himself.

Desmond Walmsley died 10 days after entering the mainstream prison, having never received any psychological assessment from Corrective Services or Justice Health staff.

Walmsley’s welfare officer admitted at the inquest that she did not read Walmsley’s "discharge summary" -- a document summarising an inmate’s previous periods of incarceration -- when assessing whether he was at risk of suicide, breaching Recommendation 157. Corrective Services’ internal guidelines on the use of discharge summary forms state: "The information is crucial to screening staff when receiving an inmate back into custody, for checking such matters as the inmate’s behaviour, medical issues, management alerts etc. Staff, Case Management Teams and the Classification Consultative Group also use the form to check that information is accurate and to obtain an overview of the inmate’s general interaction and behaviour during their past period in custody."

Had Walmsley’s welfare officer checked his discharge summary during the assessment, she would have read the following: "Mr Walmsley is considered a high risk of self harm due to the following factors: Recent serious attempt to kill himself; charged with capital crime of murdering his partner; history of suicidal ideation; recent incarceration, on remand, and first time in custody; few social supports in community and custody." The summary had been prepared following Walmsley’s discharge from the Acute Crisis Management Unit -- a specialist unit for safe and humane crisis intervention at Long Bay Correctional Centre -- eight days prior to the assessment.

In his findings, delivered in August 2009, deputy state coroner Paul MacMahon commented: "It would be anticipated that the early period of transition from the intense supervision of the ACMU to the mainstream prison would be likely to be the greatest time of need for an inmate who is at risk of self harm and as such Mr Walmsley ought to have been reviewed during that time."

Corrective Services NSW and Justice Health were contacted for comment but did not return emails or phone calls.

*This is the second in a series of case studies and investigative reports into prison deaths. Next week, the warning signs before the 2007 hanging death of Aboriginal inmate Adam Douglas Shipley.