Inquest Into The Manner And Cause Of Death Of Mark Robert Watson

THE CORONER'S COURT ) IN CANBERRA IN THE ) CD 179 of 1996

AUSTRALIAN CAPITAL TERRITORY ) INQUEST INTO THE MANNER AND CAUSE OF DEATH OF MARK ROBERT WATSON Mark Watson was arrested by the police on the 13th of June 1996 and charged with two offences arising out of an incident in which it was alleged that he had stabbed Phillip Geoffrey Walsh, who was the defacto husband of his mother. He was at the time of his arrest 17 years of age and, therefore, subject to the provisions of the Children's Services Act 1986 (CSA). A child taken into custody for an offence in the Australian Capital Territory comes under the provisions of the Children's Services Act 1986 (CSA).

Section 5 of the CSA is in the following terms: "(1) In any proceedings in a court having jurisdiction in the Territory, whether the proceedings are under this Act or under some other law, being proceedings against or concerning or affecting a child, the court shall, in the exercise of its jurisdiction or powers, seek to procure for the child such care, protection, control or guidance as will best lead to the proper development of the personality of the child and to the child's becoming a responsible and useful member of the community.

(2) In the exercise of a power, whether under this Act or under some other law of the Territory, by a body, authority or person, being a power the exercise of which affects or concerns a child, the body, authority or person shall seek to procure for the child the matters referred to in subsection (1).

(3) Subject to subsection (4), for the purpose of subsections (1) and (2), the court, body, authority or person shall have regard to such matters as seem to it or the person to be appropriate and, in particular, to such of the following as are appropriate:

(a) the need to strengthen and preserve the relationship between the child and his or her parents and other members of his or her family;

(b) the desirability of leaving the child in his or her own home;

(c) the desirability of allowing the education, training or lawful employment of the child to be continued without interruption or disturbance;

(d) the desirability of ensuring that the child is aware that he or she must bear responsibility for anything that he or she does that is contrary to law; and

(e) the need to protect the community or a particular person from the violent or other unlawful acts of the child.

(4) For the purposes of subsections (1) and (2), the court, body, authority or person shall regard the best interests of the child as the paramount consideration.

(5) In subsection (4)- "interests", in relation to a child, includes matters related to the care, welfare or development of the child."

Section 38 of the CSA where relevant is in the following terms: "(1) Subject to this section, a child who has been charged with an offence and is not admitted to bail shall, as soon as practicable, be taken to a shelter, and shall be detained there." A shelter is defined in section 4 of the CSA as: "shelter" means a shelter established or declared by the Minister under section 157" Section 157 of the CSA is in the following terms: "The Minister may, for the purposes of this Act-

(a) establish shelters, attendance centres and institutions; and

(b) in writing, declare that a place which is, at the date of commencement of this Act, used as a shelter, an attendance centre or an institution, in relation to the care of children, is to be a shelter, an attendance centre or an institution, as the case requires, for the purposes of this Act." The effect of section 5 of the CSA is to impose a statutory responsibility upon the court, the police and Quamby to procure or to seek to procure for the child such care and protection in accordance with the terms of the Act.

Mark Watson was taken into custody by the police and the bench sheet on his Children's Court file, number CH 10283-84 of 1996, indicates that he was apprehended at 9:55 p.m. Bail had been refused by the relevant police officer at the police station. He was taken from the police station and placed in custody at the Quamby Youth Detention Centre (Quamby) (I note in passing that inquiries from the National Library of Australia indicate that the word Quamby is of North Queensland derivation and means to stop, to lie down and to rest or camp) during the A shift (11:00 p.m. to 7:00 a.m.) on the evening of the 13/14 June 1996.

There is no issue in this inquest to suggest that Quamby was other than a shelter approved pursuant to section 157 of the CSA.

The log kept in the control room at Quamby indicates that he came into Quamby in the company of the AFP at 2.50 a.m. It is not possible from the evidence to ascertain with certainty where he was placed upon his arrival but the special observation book indicates that from about 9.45 p.m. on the 14th of June he was subject to 5 minute observations. This book further indicates that from 11.05 p.m. on the 14th of June 1996 he was in room 808.

Mark Watson appeared in the Children's Court on the 14th of June 1996, bail was refused and he was remanded in custody. He was remanded to appear in the Children's Court on the 21st of June 1996.

Mark Watson re-appeared in the Children's Court on the 21st of June 1996 and was remanded to the 24th of June 1996. Bail was again refused and he was returned to Quamby.

On the 24th of June 1996 Mark Watson again re-appeared in the Children's Court and was remanded until the 8th of July 1996. He was granted bail on certain conditions, including a condition that he was to attend at Arcadia House for detoxification and that he was not to approach his mother, Mr. Walsh or the suburb of Calwell. On this date he was remanded to re-appear in the Children's Court on the 8th of July 1996.

On the 8th of July 1996 he re-appeared in the Children's Court, a plea of not guilty was entered to the charges, and the matters were fixed for hearing for the 16th of October 1996. Mark Watson was bailed on condition that he attended at a rehabilitation centre called Dunlea which is located in New South Wales. His father acted as a surety in relation to his bail.

The evidence indicates that this placement was not a success and Mark's father attended at the Centre and returned his son to Canberra. His father took him the next day, the 10th of July, to see Ms. Fiona Flynn, a drug and alcohol counsellor. Ms. Flynn took certain action under the provisions of the CSA and the Mark's circumstances were brought to the attention of the Child Protection Unit of Family Services.

The Child Protection Workers, Ms. Shaw and Ms. Cusack conducted an assessment of Mark at Quamby and following this assessment took him to The Canberra Hospital where he was assessed by Dr. Westcombe.

Following this assessment Dr. Westcombe recommended the admission of the Mark, at least, overnight at the

hospital. The admission was not possible at the time of the assessment and Mark remained in the company of the child protection workers during the course of the afternoon and was ultimately taken to the hospital in the early evening when he was admitted.

The next morning Mark was assessed by Dr. Burnand and following that assessment he was discharged from the hospital into police custody.

Mark was returned to Court and was re-admitted to bail on condition that he reside with his father. This bail order was made on the 11th of July 1996 and included a condition that he be subject to supervision by the Director of Family Services.

On the 29th of August 1996 his father made an application to the Court to be discharged as the surety in relation to his son's bail. In accordance with the provisions of the Bail Act a warrant was issued for the arrest of Mark Watson so as to bring him before the Court in relation to the application made by his father.

The young person appeared in the Children's Court on the 13th of September 1996 when his father was discharged from his surety and the charges preferred against him remained fixed for hearing on the 16th of October 1996. Bail was refused and he was returned to Quamby.

Mark Watson appeared in the Children's Court on the 16th of September 1996 and was remanded until the 23rd of September 1996. He was bailed to attend at The Canberra Hospital for examination and possible admission.

He was not admitted to the hospital and returned to Court later in the day, when he was again remanded to the 16th of October 1996 for hearing and bail was refused. His papers were at that time marked that he was to be regarded as a detainee at risk.

Mark Watson was found hanging in unit 5 of the Special Needs Unit in the early morning of the 17th of September 1996. He was subsequently taken to The Canberra Hospital where he died on the 21st of September

1996. He was 17 years old.

The death of Mark Watson became the subject of an inquest under the provisions of the Coroner's Act 1956 (the Act) The inquest into the manner and cause of the death of Mark Watson commenced on the 3rd of November 1997 and continued, on and off, until the 19th of December 1997. For reasons largely outside the control of the Court the inquest did not resume until 12 October 1998 and continued until its conclusion on the 6th of November

1998. In all, there were some 34 hearing days involving taking evidence from some 47 witnesses.

The Role of the Coroner The Coroner's Act 1956 (the Act) provides in section 12 as follows: "A Coroner shall, subject to this Act, hold an inquest into the manner and cause of the death of a person who - . . . . .

(k) dies in custody." Section 24 of the Act states: "The Coroner holding an inquest into a death in custody shall include in a record of the proceedings of the inquest findings as to the quality of care, treatment and supervision of the deceased person which, in the opinion of the Coroner, contributed to the cause of death".

Section 25 of the Act provides, inter alia, for the Coroner after the completion of the inquest to provide a report to various nominated persons or organisations.

Section 56 states: "(1) A Coroner holding an inquest shall find, if possible -

(a) the identity of the deceased;

(b) how, when and where the death occurred

(c) the cause of death;

(d) the identity of any person who contributed to the death; and

(e) in the case of the suspected death of a person - that the person has died.

. . . . .

(4) A Coroner may comment on any matter connected with the death or fire, including public health or safety or the administration of justice." Section 58 states: "(1) A Coroner may report to the Attorney-General on an inquest or inquiry which the Coroner has held.

(2) A Coroner may make recommendations to the Attorney-General on any matter connected with an inquest or inquiry, including matters relating to public health or safety or the administration of justice." Section 59 provides a procedure whereby a Coroner may deal with a person who in the view of the Coroner has committed an indictable offence.

It is clear from the provisions of section 24 of the Act that the Coroner holding an inquest into a death in custody is required to consider all of the events which took place between the time the deceased was taken into custody and the time of his death. It is necessary, in my view, for these matters to be canvassed in some detail so as to ascertain whether anything relating to the care, treatment and supervision of Mark Watson while in custody contributed to the cause of death or whether any person contributed to the death.

It is important to state that the inquest into the death of Mark Watson is limited by reason of the provisions of the Act. The inquiry conducted by me was not an inquiry into all of the circumstances of the running and administration of Quamby. While it was clearly necessary to extend the inquiry outside events actually relating to the custody of Mark Watson it is not the role of the Coroner in this inquest to canvass the entire running of Quamby.

During the course of the evidence in November and December 1997 issues were raised by a number of witnesses concerning allegations of problems which they believed may have been relevant to the circumstances surrounding the death of Mark Watson. This evidence indicated, according to those witnesses, that there had been a long standing dispute involving various members of the staff at Quamby and that there had been various inquiries and complaints made into and about the operations of Quamby. These allegations led to a number of persons at the management level of Quamby being separately represented. During the adjournment of the inquest between December 1997 and October 1998 further inquiries were made at my direction by the Australian Federal Police and a number of statements were obtained from various past and present employees at Quamby. Upon the resumption of the inquest in October 1998 I announced that in my view it was not appropriate or relevant in the circumstances of the inquest to conduct an extensive inquiry into the allegations which had been made during the evidence in November and December 1997 further details of which were contained in the various statements which had been obtained by the police. I indicated that it was my intention not to pursue those allegations in any detail, but to refer all of the material contained in the statements, together with other relevant material, to the Attorney-General as part of my report at the end of the inquest.

As a result of this decision while it was ultimately unavoidable that some exposure occur in relation to these types of complaints the extent of the investigation into those complaints has been limited and certainly was not the role of the inquest into the death of Mark Watson.

BACKGROUND OF MARK WATSON Mark Watson was born on the [redacted] 1979, the youngest child of Peter Watson and Judith Watson.

(The material below has been taken from the statements of Judith May Watson, Exh. 103 and Peter Mark Watson, Exh. 106) Mr. and Mrs. Watson were married in Canberra in May 1976 and there are two children of that marriage, Donna Lee Watson, born the [redacted] 1977 and Mark Robert Watson, born on the [redacted] 1979. Mark Watson had lived in Canberra all of his life and was educated at various schools including Kambah High, Dairy Flat and The School Without Walls. He left school in September 1995 without achieving any formal educational qualifications.

He had difficulties at school from a young age and was diagnosed as a small child as being borderline hyperactive. He engaged in counselling and occupational and physical therapy while still in primary school. The behavioural problems exhibited by him during his school years caused particular problems for him and it would

seem that as a result of these difficulties he was unable to achieve at school. His parents became aware of his use of cannabis when he was about 14 years of age.

His parents separated in about March of 1994 and both children remained with their father. Mrs. Watson began to live with Phillip Geoffrey Walsh in about August of 1994.

Mark Watson first became involved with drug and alcohol counselling in 1995 and became involved with FACES.

There are suggestions of at least one incident of self harm when his wrists were lacerated.

In January 1996 his father became increasingly concerned about Mark's excessive use of cannabis and asked his son to leave his house. At that time he was taken by his father to seek further counselling. His father indicates that following his request for his son to leave the house he ultimately arranged for him to reside at the Lasa Refuge at Waramanga where he stayed for a period but was ultimately asked to leave. He then returned to live with his father. He was enrolled at the Fyshwick TAFE under a CES scheme of introduction to mechanics but this did not seem to work out.

In early June 1996 there was an incident between Mark Watson and his father at his father's residence in which his father states that Mark threatened him with a knife. His father struck him and again requested that he leave the house. His father indicated that he would not be allowed to return without first embarking upon some form of rehabilitation for his drug problem and also after undertaking some form of counselling in relation to his behavioural problems.

Mrs. Watson in her statement indicates that on the 11th of June 1996 her son came to stay with her. Mark had stayed with his mother on a number of occasions for short periods previously but these, it seems, had always ended in dispute between Mrs. Watson, her son and Mr. Walsh. On the 11th of June when he came to stay she indicated to him that he would not be able to stay over the weekend as she and Mr. Walsh were going away for the weekend and she was apparently not prepared to allow Mark to stay in the residence alone.

An argument developed between Mrs. Watson, her son and Mr. Walsh on the evening of the 13th of June 1996 at about 5:15 p.m. and continued for some hours. During the course of this argument Mr. Walsh sustained the injuries that led to the charging by the police of Mark Watson.

Mark Watson came into police custody on the 13th of June 1996.

FIRST REMAND IN QUAMBY Mark Watson was taken into custody by Const. Stoykovski and the bench sheet of exhibit 270 indicates that that occurred at about 9.55 p.m. He was taken to the Tuggeranong Police Station and interviewed in relation to the incident involving Mr. Walsh. Certain observations were made by Const. Stoykovski concerning the state of mind of Mark Watson. He was then taken by Const. Stoykovski to the City Watch House where he was charged. A document was created at the police station by the charging sergeant, which is now exhibit 31. This document contained, amongst other material, a comment that the mother had indicated previous suicide threat. It is not clear from the evidence whether this document was transferred with Mark Watson to Quamby when he was taken there early in the morning. It certainly does not appear in his dossier.

The evidence indicates that upon arrival at Quamby a young person is subject to an induction interview. The dossier contains such a document dated 14.6.96 and timed at 3.04 a.m. This document contains a number of questions which require a notation to be made by the inducting officer. These include an indication of psychiatric treatment and drug usage. The induction interview prepared, it would seem, by Mr. Richard Rueben, was negative insofar as previous psychiatric treatment was concerned but indicated that Mark Watson had taken "dope" as recently as the 10th of June. The induction interview indicates that the young person had had no previous drug treatment and had no convictions.

The control room log, exhibit 197, indicates that on the 14th of June 1996 the AFP attended at the centre with remand (sic) Mark Watson at 2.50 a.m. The control room log indicates that Mr. Withers was on duty as the senior worker. There are no details in the control room log as to whom, if anyone, was on duty with Mr. Withers. The absence of these details seems to be a failure on the part of Mr. Withers to properly complete the control room log.

An inspection of the handover sheet for that particular shift, namely the A shift for the 13/14 June 1996, indicates that Mr. R. Rueben was on duty together with Mr. C. Withers.

There is an entry on the back of the handover sheet for the next shift which, as I understand the procedure, would have been placed there by Mr. Withers which says new remand (sic) Mark Watson cc 14.6.96. These documents, that is to say the induction interview, the entry in the control room log and the entry in the handover sheet seem to represent the total documentation in relation to the entry into Quamby on this occasion of Mark Watson.

There is no written documentation, and no clear oral evidence, to indicate what happened to Mr. Watson upon his admission to Quamby other than what is found in the special observation book, exhibit 69. This book indicates that commencing at 9.45 on the 14th of June Mark Watson was on 5 minute observations. While the entry does not indicate whether it was 9.45 a.m. or 9.45 p.m. it would seem from looking at the handover sheets for the B and C shifts on the 14th of June that it is during the C shift, which commenced at 3.00 p.m. and concluded at 11.00 p.m., that the observations commenced.

I note that the initials beside the entries commencing at 9.45 would seem to be EH and that an E. Hartig was on duty as part of the B shift that day. I also note, however, that E. Hartig was on duty as part of the C shift for that same day.

I note further that an entry appears between the times 10.50 and 10.55 in the following terms "A shift five minute observations Mark Watson - staff L. Schloss". An L. Schloss, according to the handover sheet, was part of the team on duty for the B shift on the 14th of June but not for either the C shift or the A shift. A further entry at the bottom of that same page would seem to say 11.05 p.m. and certainly on the next page headed 14.6.96 five minute observations L. Schloss noting that Mr. Watson was in room 808 indicates that that new page of entries commenced at 11.05 p.m. This would suggest that the entry commencing at 9.45 was 9.45 p.m. It is difficult, however, to understand from the shift handovers as to how it was that L. Schloss was recording entries on the A shift which commences at 11.00 p.m. and runs to 7.00 a.m. when there was no suggestion that L. Schloss was on duty according to the shift handover sheet.

The control room duty log indicates that L. Schloss was on duty on the shift commencing at 7.00 a.m. on the 14th of June and had been assigned to the eight bed unit. L. Schloss is not recorded in the log as continuing on duty for the 3 p.m. shift but is recorded as being on duty commencing at 11.00 p.m. together with Mr. Withers and M.

Richardson. For some reason L. Schloss is not included on the handover sheet as being on duty for the A shift of the 14/15 of June. It would also appear at that time that if the five minute observations did commence at 9.45 then the evidence suggests that Mark Watson was at that time in the eight bed unit and not the six bed special needs unit.

The observations performed by L. Schloss continued until 6.55 when they were taken over by a member of the B shift and continued, according to the entries in the special observation book, at 15 minute intervals until 8.30 a.m.

when Mark Watson was released from his cabin. The entries for the 15th of June indicate between 2.30 and 3.30, one assumes p.m., that Mark Watson was checked every five minutes in his unit and then released at 3.30 from his unit. The observations recommence at 7.00 p.m. on a 5 minute basis and the book indicates that a number of workers were involved in those observations until L. Schloss took over again at 10.40, one assumes p.m. The observations were continued by L. Schloss at 5 minute intervals until that person ceased signing entries at 5.50 a.m. There are two other entries in the book at 5.55 and 6.00 a.m. signed, it would seem, by someone other than L. Schloss and then while there are times written in the book from 6.05 to 6.55, inclusive, there are no entries of any description. The entries resume on the B shift at 7.00 a.m. on the 16th and continue at 5 minute intervals until 7.25 when the entry then indicates that there were five minute observations until 8.35 when Mark Watson was released from his unit.

The entries recommence on the 16th of June at 2.30 and continue at five minute intervals until 3.20. They then resume on the 18th of June 1996 at 8.00 which looking at the other entries would seem to be 8.00 p.m. and continue at various times between 8 until midnight. The observations recorded in the book do not follow initially any particular pattern but there are entries for 8.00, 8.30, 8.30, 9.30, 10.00 and thereafter each 15 minutes until midnight. It appears from the special observation book that the observations for this period of time were conducted by someone with the inititals RH. The entry in the special observation book does not indicate whether the observations were made on the evening of the 17th/18th or 18th/19th. If one looks at the handover sheets for the 17th/18th it appears that R. Hutchinson was on the A shift for that date. If one looks at the handover sheets for the 18th/19th R. Hutchinson does not appear as part of the staff for that evening, however, the control room log for the 18th to 19th of June indicates that "Mrs. Hutchinson out of centre" this entry being made at 12.00 midnight. The handover from the C to the A shift on the 18th of June in the control room log indicates that Ms.

McKenzie was the shift supervisor for the 18th of June C shift and the handover sheets indicates that that is so.

The handover sheets indicate that Mr. Mewburn was the shift supervisor for the C shift of the 17th and handed over to Ms. Richardson for the A shift for the evening 17/18.

It is difficult to follow these particular entries but it seems on balance that the entries dated the 18th of June, which ended at 12.00 midnight, are more likely to coincide with the evening of the 18/19 June as Mrs. Hutchinson left Quamby at that time. R. Hutchinson had been a member of the C shift for the 18th of June under Ms.

McKenzie and it appears likely that that person must have continued on duty until midnight of the 18th of June.

It is very difficult to ascertain from the observation book, the control room log and the shift handovers as to precisely what was supposed to be occurring with Mark Watson during that period of time. It is clear, however, from entries in the handover sheets that there were concerns about his circumstances. As mentioned above he was in custody between the 13th of June and the 24th of June and there are at least 13 entries during that time appearing in the handover sheets. These entries are as follows:

1. The first entry indicates his admission into Quamby on the 13/14 of June 1996.

2. On the 14th of June entries were made, as I understand the system, by Mr. Mewburn on the B shift indicating that Mr. Watson was remanded until the 21st of June 1996 and a further entry in the following terms: "Mark Watson needs to be seen by a doctor. Unable to contact Dr. Rowland - left message for Dr. Dugdale to contact Quamby. (I note in passing that an entry in the control room log for 4.00 p.m. on the 14th of June 1996 indicates that Dr. Rowland was in the Quamby centre. I am not aware of any evidence to indicate whether Dr. Rowland saw Mark Watson on that day)

3. On the 14th of June 1996 an entry was made by the C shift, Mr. Hess, in the following terms "Mark Watson is an extremely high security risk. Five minute obs whilst in his room". The C shift commences,as I understand it, at 3.00 p.m. and concludes at 11.00 p.m. and that entry made on Mr. Hess' C shift would seem likely to indicate the commencement of the special observation entries in the special obs book at 14.6.96 at 9.45 p.m.

4. On the 15th of June 1996 on the B shift an entry was made by Ms. McKenzie in the following terms "R. Hertel has suggested that Mark Watson use only plastic cutlery. The three residents can all use plastic for the time being". There is a further entry at the bottom of the notes in the following terms "Mark Watson still unsettled" and immediately below that "six bed residents demanding". It is difficult to know whether these series of entries are intended to indicate that as at that date, that is the 15th of June B shift, Mark Watson was then in the six bed unit or still in the eight bed unit. There is nothing in the special observation book to indicate any change from the entry made by L. Schloss at 11.05 p.m. on the 14th of June which would suggest that he was in 808, the eight bed unit.

5. There are entries for the 16th of June B shift of which Ms. McKenzie was the shift supervisor in the following terms "Re A shift no requirement for extra staff on A shift tonight as Mark Watson has been sleeping soundly all night" and "six bed residents very demanding. Mark Watson is aware that he is not allowed contact".

6. There is a further entry on the 16th of June 1996 C shift written by Mr. Mewburn indicating that there was a letter to be posted for Mark Watson and a further indication that this was done on the 17th of June.

7. There is an entry on the shift handover sheet of the 16th of June 1996 A shift which, as I understand the process, is an entry which would have been made by either Mr. Withers or Ms. Richardson in the following terms: "Mark Watson very unsettled til 12.00 a.m. see report". A report is contained in exhibit 263 entitled Memo addressed to Mr. Hertel from the A shift supervisor and signed by Mr. Withers. That report refers to an incident which occurred at approximately 11.30 p.m. on the 16th of June when Mr. Withers indicates he heard a loud noise coming from the six bed building and entered that building and noticed Mark Watson in a state of agitation, punching the brick work near the shower recess. A towel was hanging over the wall to provide a cushion from severe injury. This report goes on to indicate that Mr. Withers attempted to talk to Mr. Watson through the window but was unable to understand what was being said. Mr. Withers returned to the control room, collected a key and accompanied by Mrs. Richardson returned to the six bed building where they both entered Mark's unit and were immediately aware of his obvious distress. Mr. Withers removed certain items from his unit that could have caused injury. The report indicates that a lengthy conversation then took place between Mrs. Richardson and Mark Watson and that ultimately Mrs. Richardson succeeded in calming him down and he appeared settled and they left his unit. The note indicates that 15 minute observations were maintained until approximately 2.00 a.m. It is appropriate at this time to make a number of comments concerning this particular incident. The first is that it appears at that time that Mr. Hertel was the acting manager of Quamby and accordingly the memorandum was addressed to him presumably in that role and not necessarily in his role as the psychologist. Secondly, it is significant that if one looks at the entries in the special observation book there is no support in that book in relation to the occurrence of the incident involving Mark Watson. I do not say this to suggest that Mr. Withers or Ms. Richardson have invented the incident, but merely to indicate a failure in relation to the documentation at Quamby. The special observation book for the relevant period indicates that between 7.00 a.m. on the B shift of the 16th of June observations were carried out at 5 minute intervals until 8.35 a.m. I am not able to ascertain who made these observations but it is clear that when the observations resumed at 2.30 p.m. the same signature appears against those observations as appeared against the earlier observations. While not in appropriate form

as I understand them the observations at 5 minute intervals commenced at 7.00 a.m. and ended at 8.35 a.m.

when Mark Watson was released from his cabin. They resume, it appears, at 2.30 p.m. and continue as follows: 2.30, 2.45, 2.50, 3.00, 3.15, 3.30. There are no observations recorded in the special observation book until the 18th of June 1996. Mr. Withers indicated in his note to Mr. Hertel that 15 minute observations were maintained from the time of the incident at about 11.30 p.m. until 2.00 a.m. There is nothing in the special observation book to indicate this occurred.

I note in passing that the control room duty log for the 16th of June indicates an entry at 11.30 p.m. "residents checked residents in cabin 606 was very upsett and was pacing his room". This entry I would assume was made by Mr. Withers. A further entry described as a late entry at 11.45 after an entry timed at 12.05 indicates that the resident in cabin 606 was settled.

8. A further entry appears for 17.6.1996 B shift which I assume was written by Ms. McKenzie in the following terms "Mark Watson has been quite upset today. A close eye will need to be kept on him. R. Hertel is looking at getting a doctor to see him. We can utilise the Mental Health Crisis Team after hours if required".

9. A further entry appears on the 17th of June 1996 for the C shift which I assume was an entry made by Mr.

Mewburn to the effect "six bed residents a bit demanding".

10. A further entry appears on the shift handover for the 18th of June A shift written I assume by Ms. Richardson and is in the following terms: ". . . and Mark Watson do not seem to exist as far as assessments is concerned - could day shift seniors please attend.

11. The remaining entries on the 19th of June C shift, 22 June and 24 June indicate that Mr. Watson was either to go to court tomorrow or had been bailed.

This chronology would indicate that during his first period on remand Mr. Watson presented particular problems part of which at least related to a difficulty he was then experiencing with his girlfriend leaving Australia. This situation was no doubt compounded by the problems with his mother and father. One of the matters which clearly are raised by this review of the evidence is the lack of any information readily available, or indeed available at all, to trace the path of what was occurring to Mark Watson during this period. There is no record of who made the decision when he first came into custody as to his placement, there is no record as to who authorised the institution of the original five minute observations, there seems to be no incident report relating to the matter referred to in the entry on the A shift of the 16th of June, but there is a Memo in a typed form addressed to Mr.

Hertel.

There are various changes in the status of Mark Watson seemingly both in relation to his accommodation which would appear initially to have been in the eight bed unit but subsequently in the six bed unit and also in relation to the detail of the special observations that he was subject to, in particular, whether he was on five, fifteen or 30 minute observations. It would seem that contrary to a lot of the evidence given by witnesses that he was housed in the eight bed unit initially but subject therein to five minute observations. The general tenor of evidence, particularly from Mr. Young and Mr. Woods, was that five minute observations would normally be conducted in the six bed unit. It is clear, however, in this situation that five minute observations were indeed being conducted other than in the six bed unit.

I would recommend that urgent consideration be given to the creation of a proper file relating to each individual detainee at Quamby which contains all information relevant to the stay in Quamby of a detainee. This file ought to be able to be perused and provide immediate information concerning the placement of the young person and if necessary any material as to why that particular decision was made, details of observations and why the decision was made for any particular special observation, especially five minute observations and any removal of those observations. It is not appropriate in my opinion to require the sort of search which has been required in this situation to attempt to ascertain what had occurred to Mr. Watson.

PERIOD BETWEEN FIRST RELEASE FROM QUAMBY AND ADMISSION TO THE CANBERRA HOSPITAL Mark Watson appeared in the Children's Court on the 24th of June 1996 and was released on bail to attend at Arcadia House. He re-appeared in the Children's Court on the 8th of July 1996 and was bailed to attend at Dunlea, an institution situated at Campbelltown, N.S.W. and apparently run by the St. Vincent de Paul Society.

He had been accepted into their program.

His father indicates that following his son's entry into the Dunlea program in Sydney he attended at that place after about one day to pick up his son and return him to Canberra. Mark had been unable to cope in the environment. Mr. Watson indicates in his statement that during the return journey to Canberra he discussed with

his son that he ought surrender himself to the police and that his son indicated he would jump out of the car if that was to occur. His father returned him to his home and contacted Fiona Flynn of the Drug Referral Information Centre. He was taken the next day to visit Fiona Flynn.

Ms. Flynn had previously seen Mark Watson on the 18th of June 1996 when he had been a resident at Quamby following his initial arrest on the 13th of June. Ms. Flynn indicated that on the occasion in June she observed that Mark was very upset and that he had some signs of physical injuries which no doubt had resulted from the incident with Mr. Walsh on the 12th of June 1996.

Ms. Flynn indicated that she had spoken with an officer of Juvenile Justice concerning her anxieties in relation to Mark and she understood that following her discussion in June he had been the subject of an assessment by Mr.

Hertel, an intern psychologist at Quamby. Between the discussions of the 18th of June and the 10th of July Ms.

Flynn had continued to keep in contact with Mark Watson by phone.

Upon his attendance on the 10th of July 1996 Ms. Flynn was concerned about his circumstances and accordingly arranged for him to contact Ms. Shaw and Ms. Cusack, child protection workers.

Ms. Shaw and Ms. Cusack interviewed Mark at Quamby on the 10th of July 1996. Ms. Shaw in her evidence indicated that both she and Ms. Cusack had a serious concern about the mental health of Mark Watson and they believed that he was a moderate to high risk of self harm. As a result of this assessment they discussed with Mark the prospect of him attending at the The Canberra Hospital to be assessed by a psychiatrist. He agreed to do so and the two child protection workers transported him to the hospital where he was assessed by Dr.

Westcombe.

ADMISSION TO THE CANBERRA HOSPITAL Dr. Westcombe was at that date employed as a psychiatrist at the The Canberra Hospital. It was in this capacity that he examined and assessed Mark Watson.

There is no dispute on the evidence that at the time of this assessment on the 10th of July 1996 that there was a substantial concern on the part of the child protection workers in relation to the lack of suitable accommodation for Mark. This fact was in addition to the other concerns held by the child protection workers relating to his physical and mental well being.

Dr. Westcombe, following his assessment, formed the view that it was appropriate to admit Mark to hospital at least overnight. He was asked by Mr. Buddin (Transcript 11.11.97, page 8): And on what basis did you admit him? What were the factors that led to you admitting him?---Well, a number of factors in combination led to the decision. One was the fact that these Family Services workers seemed quite genuinely to be saying to me there was nowhere else for him. Secondly, he did appear to me to be depressed and thirdly, he was accepting of admission and there were - he did appear to be - there did appear to be some concern about his state - I had some concern that he stated some intention, or - no, that's - no --- His what intention?---No, I'm going to rephrase it, because that's not quite correct. He did say he had some concerns about his own safety. I'll rephrase it.

He was asked the following question (Transcript 11.11.97, page 9): And what was the purpose of admitting him?---I suppose a combination of things. A combination to see if we could sort out something appropriate, and secondly, to observe him and if necessary treat the depression further.

And to, I suppose those were - that would sum it up, yes.

Some questions were asked of Dr. Westcombe, as there were of Doctors Hughson and Burnand, in relation to difficulties presented by the potential shortage of beds. Dr. Westcombe indicated in relation to the first admission that this was not a consideration which weighed with him as following his assessment he was of the view that it was appropriate to admit Mark and this was done notwithstanding any problem there may be in obtaining a bed for him.

It is appropriate, however, to indicate at this point in time that each of the medical practitioners called, namely, Doctors Westcombe, Hughson and Burnand all commented upon a perceived problem with the shortage of beds which were available for the treatment of psychiatric patients at The Canberra Hospital.

Dr. Westcombe indicated that further consideration would have to be given by the medical practitioner who was in charge the next morning.

Following the decision to admit Mark Watson to hospital the evidence indicates that that admission did not occur at that particular time. He returned in the company of Ms. Shaw and Ms. Cusack to their place of work where he remained during the course of the afternoon and early evening. He was transported back to the hospital by the child protection workers and admitted to the hospital at about 7:30 p.m. on the evening of the 10th of July 1996.

He resided in the hospital overnight and was subjected to a further examination the next morning by Dr. Burnand.

Dr. Burnand was employed at The Canberra Hospital as a resident medical officer and was at the particular times attached to the psychiatric unit as part of her ongoing training. She was subject to direct supervision by, amongst others, Dr. Hughson. Her evidence indicates that she examined Mark on the morning of the 11th of July 1996 but was not able to find any basis upon which she could justify him remaining in the hospital as an inpatient. Her evidence indicates that following her examination she rang Dr. Hughson but at that point in time was unable to speak to him. She then spoke to Dr. Westcombe. Either during or after that discussion she spoke with Dr.

Hughson. She indicates that Dr. Hughson was aware of Mark as Dr. Westcombe had discussed the patient with him the night before.

Dr. Burnand was asked by Mr. Buddin (Transcript 10.11.97, page 14): What was the presenting problem?---The presenting problem was a 17 year old who essentially came in the night before in the company of Family Service workers and there were two problems; the first was that they were concerned about his mood and wanted some sort of assessment of him. They felt that he had evidence of a depressed mood and the second problem was that he essentially had no accommodation at that time.

She was then asked: And I think you accepted that there was evidence of a depressed mood?---There was evidence of a depressed episode in the context of a number of significant stressors. So, that wasn't - I didn't believe that he had a biological depression which warranted medication or treatment.

You had some concerns about suicidal ideation?---I had some concerns. When dealing with any patient who presents with a depressed mood, particularly in this adolescent age group, one of your primary objectives of any interview is to discuss with them suicidal ideation and even if they don't raise it as an issue, you should explore that with them. That is part of the assessment.

Dr. Burnand went on to indicate in her evidence that she was probably more cautious than her senior colleagues as a result of her inexperience but notwithstanding this degree of caution she was of the view that there was no basis upon which she could recommend the continuing admission of the young person. This was because she was unable to find any "biological depression which warranted medication or treatment".

Pressed by Mr. Buddin (transcript 10.11.97, page 20) as to whether she would, with the benefit of hindsight, have made a different assessment she indicated that she did not believe she would do so.

The doctor indicated that she knew during the course of her assessment of Mark that the police were interested in taking him into custody if he was not detained at the hospital. This was because he was then in breach of his bail which required him as of the 8th of July 1996 to reside at Dunlea. She indicated: (Transcript 10.11.97, page 20): ---The discharge plan was to - that firstly in the context of our assessment that he didn't required (sic) continued in-patient care, that he was able to be discharged. And that he didn't require any medication, such as an antidepressant medication that that was not required. And that he was being discharged to the care of the police and to the family service people, I understand were going to try and find him somewhere else to stay.

As a result of her assessment and the decision made in consultation with Dr. Hughson Mark was discharged into the custody of Constables Sjollema and Seppings and returned to the Children's Court where he was released on bail to reside with his father.

PERIOD BETWEEN ADMISSION TO THE CANBERRA HOSPITAL AND SECOND REMAND PERIOD AT QUAMBY Mark Watson re-appeared in the Children's Court on the 11th of July 1996 following his apprehension at The Canberra Hospital and was remanded on bail until the 16th of October 1996 for hearing in relation to the charges.

He was granted bail plus a surety with a condition, for the first time, that he accept supervision of the Director of Family Services and to undertake such treatment as directed. It was a further condition that he was not to approach his mother or Mr. Walsh or the suburb Calwell. His father undertook the role of surety in relation to this bail.

As a result of the imposition of the condition of supervision Mark Watson came under the supervision of Tracy Uhle, a Juvenile Justice worker. She first saw Mark on the 23rd of July 1996. Between that date and the 13th of September she continued in contact with him and attempted to put into place some form of program which might be for his benefit. During this period Mark Watson also had contact with a Mr. Bradley Foxlewin, who was at relevant times a youth worker at the Woden Community Service. Mr. Foxlewin had first contact with Mark Watson in late August 1996. It was the intention of those involved with Mark to attempt to arrange a meeting between a number of interested parties who might be able to formulate a plan to manage the various problems which were then creating difficulty for Mark Watson. It appears, however, that as a result of timing difficulties it was not possible for those persons to meet. One of the complications was that Mr. Foxlewin was only a part time worker with a substantial work load.

Ms. Uhle indicates that during her contact with Mark Watson she requested an assessment be made by the Youth Justice Psychological Service (Mr. Hertel). I understand from Mr. Hertel's evidence that while appointments were made Mark Watson did not keep them. Accordingly, no assessment took place.

Mark Watson resided at Marlow Cottage between the 12th of July 1996 and the 22nd of August 1996. It was during this period of residence that the activities referred to by Ms. Uhle and Mr. Foxlewin took place. On the 22nd of August 1996 Mark Watson left Marlow Cottage and returned to live with his father. An incident occurred on the 26th of August 1996 involving Mark Watson and his father and as a result of that incident Mark Watson booked himself into Arcadia House. He was not able to cope with Arcadia House and contacted Ms. Uhle who gave him certain instructions as to his future conduct. It seems on the basis of Ms. Uhle's evidence that he did not accept the direction given by her particularly as to his place of residence. Action was taken by Ms. Uhle to institute proceedings for breach of bail. This led ultimately to Mark returning into custody on the 13th of September 1996.

SECOND REMAND IN QUAMBY 13 SEPTEMBER 1996 TO 15 SEPTEMBER 1996 Mark Watson returned to Quamby, according to the control room log, at 2.10 p.m. on the 13th of September

1996. He once again participated in the induction process and the induction interview appears to have been conducted by a Tony Day. This interview indicates on its face that it took place at 2.45 p.m. towards the end of the B shift. There is quite a dramatic change in relation to the material contained in this induction interview as opposed to the earlier interview in June 1996. Mark Watson now indicated that he had been subject to psychiatric treatment, that he took all types of drugs, had had his last drugs on the 12th of September 1996 and that he had been in detox. There is no information available to indicate what decisions, if any, were made concerning the accommodation or observation of Mark Watson but it appears from material provided by April Masters-Smith in her record of interview that he was placed in the remand area initially.

Ms. Masters-Smith came on duty for the C shift on the 13th of September 1996 and during the course of the evening became very concerned about Mark Watson and assessed him as a suicide risk. Ms. Masters-Smith, according to her interview, had substantial training as she had previously "worked in Melbourne Juvenile Justice Centre, and we had very strict suicide training, um, and policy and procedures in place down there, and so my training had been to look out for extremely suicidal residents" (exhibit 39). She was a qualified youth worker. She raised her concerns with Mr. Withers who was the shift supervisor and, according to Ms. Masters-Smith, Mr.

Withers accepted her recommendation and arranged for Mark Watson to be moved to the six bed unit. Mr.

Withers was unable to remember this particular incident. There is nothing in any of the records or in the evidence of Ms. Masters-Smith or Mr. Withers to suggest that any specific instruction was issued in relation to special observations but it is clear from the special observation book that observations were commenced at about 10.00 p.m. on the basis of 30 minute observations. The book does not indicate the actual time but a perusal of other entries would suggest that observations commenced at 10.00 p.m. on the 14th of September 1996. It would seem in those circumstances that whatever steps had been taken by Mr. Withers they did not include a step to commence observations of Mark immediately upon his placement in the six bed unit.

The shift handover sheets for the C shift indicates a note, presumably made by Mr. Withers, addressed to Cedric (Mr. Hess) in the following terms "Cedric I think Mark Watson should see a doctor as soon as possible. Watch him he will run". Mr. Hess commenced duty on the B shift on the 14th of September 1996. There is no note on the handover notes for the 13th of September from Mr. Withers indicating that he had put Mark Watson in the six bed unit and nothing to indicate that any regime of observations had been recommended or commenced. The next entry relating to Mark Watson to be found in the shift handover sheets appears for the C shift for the 14th of September 1996, presumably written by Mr. Mewburn, and it is in the following terms "M Watson to do sweep and mop again for chores".

There is a notation in the handover notes for the 15th of September 1996 B shift, presumably written by Mr.

Hess, in the following terms "M Watson still depressed. Needs to be observed closely". The next entry in the handover sheets relates to the incident of the 15th of September 1996.

It would appear that during these few days Mark Watson's condition was clearly causing concern to the staff at Quamby but once again there is no real record to show what action, if any, was taken by anyone in relation to those concerns. The evidence of Ms. April Masters-Smith indicates that her concern was acted upon by Mr.

Withers but it is not clear from anyone's evidence as to why the observations commenced on the 14th of September 1996 and were then in the six bed unit on a basis of 30 minutes. A study of the special observation book between the commencement of those observations and the incident of the 15th of September 1996 paints an inconclusive and unsatisfactory picture. The half hour observations end at 9.30 p.m., one assumes, probably on the 14th of September and recommence as five minute observations on the 15th of September after the attempted hanging incident. There seems to be no explanation as to why those half hour observations either were required or were recorded.

RESPONSE TO THE INCIDENT OF THE 15TH OF SEPTEMBER 1996 The response by the staff and the management of Quamby to the hanging incident of the 15th of September 1996 exposes many of the systemic problems existing at Quamby as at that date and laid the foundation for the ultimate tragedy of the death of Mark Watson. In the circumstances I believe it is appropriate to look at the actions and responses of the various individuals involved after the incident of the 15th of September 1996 separately.

JAYNE LYNETTE ROWAN Ms. Rowan was a youth worker who had been employed for some four months as Quamby. She had, however, had some experience in the area of youth management for a period of four years. She had no training in juvenile institutions before her employment at Quamby but had received some basic training once she arrived. Ms.

Rowan was part of the C shift for the afternoon and evening of Sunday the 15th of September 1996. Mr.

Mewburn was the shift supervisor. There were eight workers plus Ms. Rowan and Mr. Mewburn on duty according to the shift handover sheet for that particular shift.

Ms. Rowan indicates in her statement, exhibit 235, that she had commenced duty at 7.00 a.m. on that date on the B shift and at the conclusion of that shift had been offered the afternoon shift on an overtime basis. The effect of this is that by the time she became involved with Mark Watson at about 7.30 p.m. she had been constantly on duty for a period in excess of 12 hours. This regrettably appears to be not an uncommon occurrence as at the date of the death of Mark Watson. Ms. Rowan was working on her second shift, the C shift, together with Mr.

Shore, and her duties were to supervise the residents within the six bed unit which at this time included Mark Watson. She indicates that this was the first time she had had any dealings with him.

Her evidence is that she observed, during the course of the evening, a number of the other residents in the special needs unit giving Mark "a hard time". There is evidence from other sources that suggest some, if not all, of the other residents in the six bed unit had engaged in a course of harassment and insult in relation to Mark Watson.

At about 7.15 Mark Watson made a telephone call to his father and during this conversation he became distressed. This situation was apparently observed by Ms. Rowan. She also comments that during the phone call one of the other residents was tormenting Mark.

She indicates that at about 7.30 p.m. she went to check on Mark because of her concern in relation to his upset following the phone call with his father. It was at this time that she made the discovery which has already been described.

I would like to make a number of comments at this point in time concerning the situation which then presented itself to Ms. Rowan and how that reflects, in my view adversely, upon the systems operating at that time at Quamby.

The first is that Ms. Rowan, unlike Mr. Barnwell or Mr. Sherer, had a key to enter the unit and was able to do so without delay. The second is that she had no means available to immediately cut the cord which was around Mark Watson's neck.

A number of witnesses have given evidence and made comments concerning a Hoffman knife. It ought to be noted that this incident involving Mark Watson had occurred on the 15th of September 1996 just five months after another young man had hung himself at the Belconnen Remand Centre. Some evidence was given, particularly by Mr. Young, of some inquiries being made in relation to that death so that any lessons which had become clear as a result of that death could be taken into consideration in operations at Quamby.

In the death at the Belconnen Remand Centre a Hoffman knife had been used to cut the tourniquet around the neck of the deceased person. Notwithstanding this fact no action had been taken as a result of whatever inquiries were made by Mr. Young and or others to make available either to the staff individually or at all at Quamby a Hoffman knife. It is clear that the difficulties experienced by Ms. Rowan in holding Mark Watson up and at the same time attempting to undo the knot would have been alleviated if she had on her person a Hoffman knife.

I note in passing that in the statement of April Masters-Smith she indicates that she raised this particular issue, that is to say, the need to have a Hoffman knife with Mr. Young. Her memory of Mr. Young's response was to the effect that it was not appropriate to obtain a Hoffman knife at that time as that would appear to be in some way merely responding to a situation. It is somewhat difficult to understand what Mr. Young meant by this comment. I note in fairness to Mr. Young that this comment was never put to him so seek any response but it is clear that at the time of the death of Mark Watson and for a considerable time thereafter no Hoffman knife was available to the staff at Quamby.

It is clear from the evidence of Ms. Rowan that she apparently disregarded in a commendable way an instruction which ought to have required her to await the attendance of another officer before she entered the room. This rule, as I understand it, was one well known to members of the staff and, indeed, Mr. Baker gave evidence of an incident involving another detainee, K, who had been found lying on the floor of his unit with a tourniquet of some description tied around his neck and the other end attached to part of the structure in the unit. Mr. Baker awaited the arrival of another officer before he entered the room on that occasion. Fortunately for Mr. K this delay did not cause any problem, but it is clear that there must be liberty for staff to make decisions at the time as was done by Ms. Rowan without the constant strictures imposed by inflexible rules.

Ms. Rowan, with the ultimate assistance of Mr. Shore, released Mark Watson and the matter was reported to Mr.

Mewburn. I would again comment in relation to the absence of a Hoffman knife that an additional delay was occasioned at this time as another worker had to bring some scissors from the control room. The scissors were not required as Mr. Shore was finally able to release the knot with the assistance of Mark Watson himself.

Ms. Rowan was directed by Ms. Hillhorst to prepare an incident report concerning the matter and she did this at about 10.45 on that evening. She indicates further that she attended work the next day and had a conversation with Mr. Woods and Mr. Young.

Ms. Rowan indicates in her evidence that she had participated in two handovers on that particular day but had no memory of any comment being made about Mark Watson at either of the handovers.

Her evidence also indicates that at the time she was observing Mr. Watson he was not on any special observations but was merely in the six bed unit subject to the regular half hourly observations. It is clear from her evidence that it was only her individual concern at that time that caused her to return at a time when she might otherwise not have returned to observe Mark Watson. This return, on balance, may well have saved his life.

She indicated subsequently that her memory of the conversation she had had with Mr. Woods and Mr. Young related to her well being. She could not remember any real discussion about the incident but conceded that it was possible that some discussion had taken place.

She communicated with the control room from the six bed unit by phone and subsequently spoke to the Mental Health Crisis Team who attended in response to the incident. It was after her discussion with them that she completed her incident report.

She returned subsequently to the six bed unit and spoke to Mark and observed at that time that he had a red mark around his throat and neck area.

The internal incident report prepared by Jayne Rowan appears in the dossier of Mark Watson, exhibit 58. While it sets out the details of the incident it lacks particularity concerning the mechanism which had been engaged in to allow Mark Watson to attempt to hang himself.

Ms. Rowan conducted herself commendably on this particular evening and it was as a direct result of her diligence and care in relation to Mark Watson that she made the observation that she did. It is clear on the evidence that in accordance with the regime then operating she had a number of restrictions in theory placed upon her which fortunately did not prevent her from properly providing safety for a young person in the care of Quamby. She responded to a clear need and did not limit herself to any formal regime of observations and she disregarded the rule which would have required her to wait for the return of Mr. Shore before opening the door and going into the unit.

Her response thereafter, initially alone and subsequently with the support of Mr. Shore, is highly commendable and indeed Mr. Woods made such a comment on the incident report filed on Mark Watson's dossier which, unfortunately, according to the evidence would never have come to the attention of Ms. Rowan. It seems most regrettable that a commendation of the sort endorsed upon the incident report directed specifically to the worker is not directly brought to the attention of that worker and may never be brought to anyone's attention as the system then existed. If it is worthwhile and, no doubt, in many circumstances it is, for a person in a management situation to comment favourably upon the work of a worker at Quamby, it would seem pointless unless the commendation is brought to the attention of the worker and no doubt to their superiors. There is no criticism that one could level at the work done by Ms. Rowan at that occasion. It is perhaps cavilling to make the comment that greater detail concerning the actual mechanism involved in the hanging of Mark Watson on the 15th of September 1996 may have enabled some of the problems that subsequently arose to have been more clearly contemplated.

KEVIN PHILLIP (CHARLIE) SHORE Mr. Shore was a youth worker and had been employed for approximately 14 months at Quamby. He was on duty as part of the C shift on the 15th of September 1996 and together with Ms. Rowan was responsible for the six bed unit.

He indicates in his statement, exhibit 49, that he had first met Mark Watson in June of 1996 and made some observations concerning his distress at that time.

Mr. Shore, in his statement to police, indicates that on Saturday the 14th of September 1996 he was at work at Quamby Youth Centre when he was made aware that Mark Watson was again in custody. I am not sure what Mr.

Shore means by this statement but there does not appear to be any suggestion from either the control room log or the shift handover sheets that Mr. Shore was on duty at any time on Saturday the 14th of September.

However, it is clear from the evidence that he was on duty on the 15th of September 1996 which is the relevant time.

At the time of the incident in September he was a casual employee and had other employment in addition to the work at Quamby. He was aware on the 15th of September 1996 that Mark Watson was in the six bed unit but was not aware of the reason for him being there but thought he was there because he was coming off drugs. He had no memory of any instruction to carry out any particular observations in relation to Mark Watson on the 15th of September.

Mr. Shore indicated that he had returned to the six bed unit after carrying out some other duties in relation to another detainee and found Ms. Rowan standing with Mark Watson on a shelf approximately 800 millimetres from the floor. He observed that Mark had a cord similar to a bootlace or jacket draw cord tied tightly around his neck and attached to a higher shelf. He assisted Ms. Rowan to support Mark and this enabled her to leave the unit and to call the control room for further assistance. Mr. Shore indicates that he was able to convince Mark to remove the cord from around his neck and he managed to get him down.

He indicates that he had a discussion with Mark who indicated that he had been particularly upset about the phone call from his father. He gives some evidence concerning the arrival of the Mental Health Crisis Team and that he left Mark with them.

Mr. Shore was shown a number of documents, in particular, exhibit 238 which is a handwritten internal report again with comments from Mr. Woods which had not been brought to Mr. Shore's attention. Exhibit 238 is, according to Mr. Shore, a second document that he prepared in relation to the incident. It is his evidence that this document was the first document prepared by him in relation to the incident. Also contained in the dossier, exhibit 58, is an incident report prepared by Mr. Shore which also contains comments presumably in Mr. Woods' hand which had not been drawn to the attention of Mr. Shore. Both lots of comments endorsed by Mr. Woods on the reports prepared by Mr. Shore appropriately commended him.

During his evidence Mr. Shore produced out of his pocket in court a copy of the incident report found in exhibit 58 and this document, which is identical apart from the endorsements by Mr. Woods, was marked as exhibit 237.

Mr. Shore also indicated that after Mark got down off the shelf he, Mr. Shore, gathered up all pens and pencils in the unit so that they could not be used by Mark to harm himself. He indicates that he gave this information to the Mental Health Crisis Team workers.

Nobody made any suggestion to him to carry out any other inspection of the room and neither he nor Ms. Rowan made any investigation as to how the cord which Mark Watson had used had been placed in relation to the shelf.

Mr. Shore in his report headed "Internal Report" does give a more substantial outline of the circumstances of the incident and how the cord was attached to a higher shelf but there is again no fine detail concerning this situation.

He also indicated that after he had removed the items referred to above that Mark Watson had indicated to him that that was not necessary as if he wanted to do it he could and that he could use a sheet. He indicates that he spoke for a long period of time with Mark and was unable to recall the whole of the conversation. Mr. Shore indicates that he believed that he mentioned that information concerning the sheet to the senior youth worker, Mr.

Towhidi, who was on duty on that C shift. He further believed that he had also indicated that fact to the Mental Health Crisis Team.

Mr. Shore also indicated in his statement the agitation that had been observable in Mark Watson following the phone call from his father.

He indicates that after the Mental Health Crisis Team left he returned and spoke with Mark for a period and then returned and completed the report for Quamby's file.

As with Ms. Rowan it is clear from this evidence that Mr. Shore conducted himself appropriately and his action, together with Ms. Rowan, clearly resolved what was potentially a life threatening situation. He is to be commended for his actions.

PETER MICHAEL MEWBURN Mr. Mewburn was the shift supervisor for the C shift on the 15th of September 1996. He was a senior youth worker and had been employed at Quamby for about ten and a half years.

Mr. Mewburn had taken over from Mr. Hess and indicated that he was aware of the comment written by Mr. Hess on the handover sheet indicating that M. Watson was still depressed and needs to be observed closely. He indicated that he would have verbally passed on this comment at the handover to his shift members. He indicated that the procedure followed by him was that he spoke to his senior youth worker, on this occasion Mr. Towhidi, and that Mr. Towhidi would have then briefed the rest of the staff.

He indicated in his evidence that he thought he had originally received the phone call from Ms. Rowan but when it was suggested to him that it may have been received by Mr. Towhidi he indicated he couldn't recall. He further stated that he stayed in the control room following the telephone call and that he had contacted Mr. Woods, Ms.

Hillhorst and Mr. Hertel. Ms. Hillhorst had come into the centre. He had also contacted the Mental Health Crisis Team and indicated that he had had some difficulty contacting them. He indicated that he spoke to the Mental Health Crisis Team workers after they had spoken to Mark Watson and that Mark had then been put on five minute observations. He also indicated that he understood what was to happen the next day. It is clear from his evidence that he did not leave the control room at any time and made no attempt to conduct any real investigation of what had occurred in the unit. He certainly did not carry out any inspection of the unit. He seems to have totally relied upon others when one would have thought it was his direct responsibility as the person in charge of that shift to conduct appropriate and proper investigations. He further indicated that he had made a number of entries on the handover sheet for the next shift involving Mr. Baker and others, including the notations concerning five minute observations relating to Mark Watson.

Mr. Mewburn's actual role in the incident of the 15th of September 1996 was marginal notwithstanding his responsibility as the shift supervisor. He indicated that his principal responsibility was to contact Ms. Hillhorst and that he had only rung Mr. Woods as a courtesy. He presented as a most unreliable witness. At the time of giving

his evidence in October 1998 he indicated that he was no longer employed at Quamby but was now working in the Community Unit. It would seem to me with respect to Mr. Mewburn that it would not be desirable for him to return to his former employment at Quamby. As indicated above he had been employed there for some ten and a half years, for a portion of that time as a shift supervisor and yet he indicated in his evidence that he had largely failed to carry out his proper responsibilities.

There was no suggestion that he had ever observed the observation book as he was apparently required to do under practice and procedures; he was derelict in completing the control room log and was taken to a substantial number of entries which clearly indicated a failure on his part to properly complete the log. He was not aware of an alleged incident which had occurred on the 16th of September 1996 involving Mr. Tootel and Mr. L. and his evidence was such that unless a document could be produced to assist his memory he had little, if any, memory of the events to which he was directed.

There is also some evidence to suggest that Mr. Mewburn was absent for long periods of time from the control room when he was on duty as a shift supervisor. He seemed to have some vague knowledge of matters occurring at Quamby which might have been inappropriate, for example, people being effected by alcohol or otherwise unable to perform their duties but with some exceptions he seems not to have been aware of the corruption of the system which apparently, according to some of the evidence, had occurred. All in all his evidence is not satisfactory and reveals in my view a complete failure on his part to properly carry out his responsibilities to ensure the safety and well being of children residing at Quamby.

LYNETTE HILLHORST Lynette Hillhorst was, as at the 15th of September 1996 employed by Youth Services and worked in the Community Unit. She was at that time the Court Liaison Officer. It was part of her duties in that role to be on a roster as one of the on call managers for Quamby. This position was shared between herself, Mr. Woods and Mr.

Young on a rotational rostered basis between 5.00 p.m. and 9.00 a.m. the following morning and between 5.00 p.m. on Friday's and 9.00 a.m. on Monday's. This office was provided to allow an individual to be responsible as the manager of Quamby after hours.

Ms. Hillhorst is a trained social worker and her only experience and training in relation to the role of manager at Quamby was a six week period in 1995 when she had acted as the manager. The on call manager reported directly to Mr. Young.

On the evening of the 15th of September 1996 she was contacted by Mr. Mewburn who advised her of the incident involving Mark Watson. She indicated in her evidence that it was her understanding of Mr. Mewburn's communication that Mark Watson had attempted to hang himself with long shoelaces. She also spoke to Jayne Rowan on the phone and it is her memory of that conversation that Ms. Rowan's principal concern at that time was the length of time she had been required to hold Mark up before any assistance had arrived. It does seem that Ms. Hillhorst did not receive any information from Ms. Rowan as to the mechanism involved in the attempted hanging but she accepts that it was her understanding from her communication with Ms. Rowan that if Ms.

Rowan had not taken the full weight of Mark then he would have hung.

Ms. Hillhorst indicates that she arrived at Quamby at about 9.00 o'clock and upon her arrival spoke with Mr.

Mewburn who indicated that he had not rung any of the parents of Mark Watson. Ms. Hillhorst directed him to do so and was present when he made a phone call. Significantly neither of the parents indicate that they were advised at this time of the incident of the 15th of September 1996.

Following her arrival she spoke to, in addition to Mr. Mewburn, Ms. Rowan and Mr. Shore who were quite shaken by the incident. She gave evidence that she told them to go and have a cup of tea and sit down and write out their incident reports. Ms. Hillhorst spoke to the Mental Health Crisis Team and she believed that Jayne Rowan was there at the time the Team gave their report to her. After the Crisis Team left she again spoke with Jayne Rowan and received some further details of the incident but Ms. Hillhorst's memory is that she didn't obtain any additional information from Jayne Rowan concerning the mechanism by which Mark Watson had attempted to hang himself.

She spoke with Charlie Shore and her memory of that conversation is that he told her that the material which had been used by Mark Watson had been pushed into the top of "a fitted like wardrobe thing" and that he had been standing on something which she recalled as being described as a stool. She was still under the impression following these discussions that Mark Watson had used shoelaces, or long shoelaces, as the means of hanging.

She indicated that she found it very difficult to try and picture the scene of the attempted hanging as she was familiar with the room and did not believe that there was much room for anything to be pushed the way it was described to her by Charlie Shore. She indicates "I just found it unbelievable that someone could put something in there that would take a weight". (Transcript 29.10.98, page 23). Notwithstanding this difficulty she did not go

and inspect the room. She had intended to go and talk with Mark Watson but the Mental Health Crisis Team indicated to her that he was resting and she thought it inappropriate in those circumstances to go and disturb him. She directed that he be placed on 5 minute observations.

She did not recall giving any instructions to have his room checked but felt sure that she would have because it was something that would have always been done. If she gave such instructions she would have given them to Mr. Mewburn. There is, of course, nothing to be found in any of the written documentation which suggests any such instruction was given and nothing to suggest that if the instruction was given that it was ever carried out.

The only evidence of any inspection of the room was that conducted by Mr. Shore who removed certain items from the cabin.

She indicates that by the time she left Quamby on that evening it was her understanding that Mark Watson was settled but that there was a gap or a slot somewhere near the shelves described by her as a wardrobe in the top area. Nothing was done by anyone to cause any investigation to be made concerning this potential hazard.

Ms. Hillhorst indicates that during the evening while she was at Quamby she also rang Frank Woods who was at that time the acting manager of Quamby and gave him an outline of what had occurred. Her evidence is that she did not go into much detail of what had happened other than to indicate that an attempt had been made; that the staff were very shaken; that Mark was now resting; that he had been placed on 5 minute observations and would go to the hospital in the morning. She indicated that she contacted Mr. Woods because he would be responsible in the morning for making checks on the room and arranging for crisis intervention teams for the staff.

Ms. Hillhorst indicates that she ultimately left Quamby and returned to her home where she prepared what she described as an incident report. This incident report was the subject of some inquiry of Ms. Hillhorst but she was firm that she had written a document out by hand which contained all of the knowledge that she had in relation to the matter and that she had given it to Mr. Young in his office on the morning of their discussion of the 16th of September. This document was never produced to the court and Mr. Young in his evidence indicated that he has no memory of ever seeing it. There is an issue in relation to this document and I shall consider it again in due course, but at this time I would indicate that I am content to accept Ms. Hillhorst's evidence that she did prepare such a document and that she did give it to Mr. Young.

As already mentioned, Ms. Hillhorst had directed Ms. Rowan and Mr. Shore to prepare incident reports concerning the incident and she indicates that she has no memory of seeing them at the time of her meeting with Mr. Young. She certainly does not recall them being discussed at that meeting but she assumes that they would have made their way to Mr. Young as he obtained the reports concerning all important matters.

Ms. Hillhorst impressed me as a person who was diligent in relation to her responsibilities and carried them out to the best of her ability. There was nothing about her evidence or about anyone else's evidence which would cause me to believe that Ms. Hillhorst was mistaken when she gave her evidence concerning the preparation of the incident report. It would seem logical that such a report would have been prepared by her as it was a requirement of the rules of the operation of Quamby that such reports be prepared. It is also clear that the incident had a substantial impact upon Ms. Hillhorst and it would seem logical that she would have prepared such a report at the time and in the way she says she did. As to what happened to the report remains something of a mystery but I am content to accept that it was prepared, that it contained the material that she says it did and that it was given by her to Mr. Young at the time of their meeting.

The meeting with Mr. Young on the 16th of September 1996 resulted in a decision being made to return Mark Watson to court in order that bail might be obtained to have him taken to The Canberra Hospital. The Mental Health Crisis Team had arranged during the evening before for Mr. Watson to be seen the next day by a psychiatrist. The evidence concerning the participants in this meeting is somewhat unclear but it seems on balance that Mr. Young and Ms. Hillhorst were principally involved, that Mr. Hertel came in at the end and Mr.

Woods may or may not have been present towards the end. It appears on the balance of the evidence that Mr.

Woods, if he was present, which is unclear, did not participate in any particular way as no one has any real memory of his presence. Mr. Hertel's role in the meeting seems only to be one where he arrived at the end to be instructed as to what his role would be during the course of the day. He was to attend at court with Mark Watson and Ms. Hillhorst and then transport Mark Watson, if agreed by the court, to the hospital. The principal participants in the meeting were clearly Mr. Young and Ms. Hillhorst.

It is clear at that meeting that Ms. Hillhorst conveyed to Mr. Young her understanding of what had occurred and in particular the recommendation that had been made by the Mental Health Crisis Team and it was agreed that Mark Watson would return to court and then go to hospital. Apart from those decisions, no decision seems to have been made about what, if anything, ought to be done to the unit or what, if anything, ought to be done if Mark Watson was not admitted to hospital.

It is clear from everyone's evidence that all of those involved in the care and supervision of Mark Watson, namely Mr. Woods, Mr. Young, Ms. Hillhorst and Mr. Hertel, were all of the view that that in the circumstances it was inevitable that Mark Watson would be admitted to hospital. This view clearly coloured everyone's consideration of the situation involving Mark Watson.

Ms. Hillhorst indicates that her outline to Mr. Young of the circumstances of the incident did not, she thought, go into any great detail about how the shoelaces came to be secured. She was of the view that whatever information she passed on to Mr. Young was somewhat limited as she was anxious about the time involved as she needed to arrange to have Mark Watson return to court on that day. This responsibility was hers and was her actual job, unlike the job she had as the on call manager. It was, in my view, perfectly proper for her to give her particular attention to her responsibilities in relation to getting Mark to court without the need to go into fine detail with Mr.

Young or Mr. Woods as to the precise details of the evening's events. She was entitled to assume, as she seems to have, that either Mr. Woods or Mr. Young would arrange for the necessary investigations to be made which would have turned up the problem exposed both on the 15th and again on the 17th of September in relation to the gap behind the shelf in the room occupied by Mark Watson.

Ms. Hillhorst says in her evidence that Mr. Young indicated to her that he was going to call Mr. Woods and they would go up and investigate the matter. She subsequently stated that she did not believe that he had used those precise words but that was what she understood was the effect of what he had said. This view she formed not only from what he said but from her understanding of Mr. Young's practice that he would always investigate something of this particular nature.

Ms. Hillhorst travelled with Mr. Hertel and Mark Watson to court and together they spent a considerable period of time during the course of the day with him. Ms. Hillhorst gave some evidence concerning various comments made by Mark Watson which suggested to her that he was at risk of shelf harm.

She also gave some evidence in relation to documentation created by her and was surprised in the circumstances to be told that a particular document created by her was not on Mark Watson's personal file. She was of the view that she had given all the paper work to Mr. Hertel to return them to Quamby.

Ms. Hillhorst transported Mark Watson to court and was present for the bail application and upon his return to court from the hospital. She communicated from time to time with Mr. Hertel and also indicates that she visited Mr. Young upon her return from court and gave him an outline of the day's events. She had no other contact with Mark Watson.

MENTAL HEALTH CRISIS TEAM Mr. Mewburn contacted, after some difficulty, the Mental Health Crisis Team who attended at Quamby at approximately 8.45 p.m. on the evening of the 15th of September 1996. This team consisted of Anne Rees and Johann Barbara Napier. Their evidence basically is that they had a lengthy conversation, in excess of one hour, with Mark Watson and that he settled down and promised not to do any injury to himself during the course of the evening. They arranged for him to see the psychiatric registrar in the morning and understood that 5 minute observations would be carried out until then.

JOHANN NAPIER Ms. Napier was part of the Mental Health Crisis Team and attended with Ms. Rees at Quamby. Ms. Rees in her evidence indicates that she had to leave the unit on a number of occasions to take other calls and that Ms.

Napier had more contact with Mark Watson than she did.

Ms. Napier provided a detailed statement, exhibit 46, which contains material by way of detail relating to the attempted hanging of Mark Watson and also his state of mind at the time. She indicates that she arrived at Quamby at about 8.45 p.m. and remained there until 10.00 p.m. She was spoken to by the supervisor who she says "stated that a worker had found Mark with a cord around his neck during a routine 15 minute check". She subsequently indicates that she assessed Mark in his cell and that he showed her where he obtained the cord that he had tied around his neck and how he planned to secure it to a cupboard to effect a hanging. The cord had come from a pair of track suit pants in his possession. "He said that he had stood upon a ledge on the cupboard clutching a photograph of an ex-girlfriend (who had recently gone overseas) and had spent some time standing there, crying and thinking. He admitted that he was aware that he was on 15 minute observations by Quamby staff and he felt that the likelihood of him being discovered during a suicide attempt was high. He stated that he did not want to die but would "do anything it took" to get out of Quamby".

Mark Watson indicated in his discussion with Ms. Napier that he had decided to make a suicide attempt after he'd spoken to his father on the telephone because he was angry, hurt and thought his father was "not on his side".

He further indicated that he was motivated to do this by feelings of revenge rather than a desire to die.

Ms. Napier's statement contains a much more detailed and thorough assessment and understanding of the situation involving Mark Watson than perhaps any of the evidence before the court. She indicates that she asked him what type of help he considered important if he was admitted to the psychiatric unit and that he indicated as follows:

1. Have his friends visit.

2. Be able to smoke in the courtyard.

3. Have social workers find him a flat.

4. Not have to stay in Quamby.

5. Have more freedom.

6. Have his charges dropped.

Ms. Napier indicates that she expressed concern to him that some of his expectations were unrealistic but she indicates "however Mark stated that he was certain that after he had attempted to hang himself that he would definitely be admitted. He reasoned this because some months before he had been admitted overnight and said "I'd only been thinking of doing something". He then told me that he had been thinking of self harm since being charged about three months before, and showed me a superficial scratch to his wrist that had occurred a few days ago. He told me that being in Quamby made him feel desperate - that he was away from friends and family and he had no freedom. He regarded the charges against him were unfair because no one would take into account how much his mother's boyfriend had provoked him." Ms. Napier indicates in her assessment as follows: "In general, my assessment of Mark Watson was that he was a young man in a situational crisis - very unhappy and angry with his family (especially his father) whom he believed had not supported him enough. He stated that his suicide attempt had been motivated by feelings of anger and revenge towards his father and a belief that he would be transferred to the hospital. He saw an admission to hospital as being superior to that of being in Quamby because of a perceived expectation of greater freedom and more lenient treatment. He stated on many occasions that he did not want to die and that he expected to be found by Quamby staff." It is clear from this summary of Ms. Napier's report that she had in her possession on the evening of the 15th of September 1996 very clear information concerning the precise details of the attempted suicide and an understanding of why it had occurred. It is not clear on the evidence as to how much of this detail, if any, was passed on by Ms. Napier to anyone on the Quamby staff. The evidence does indicate that there were discussions between members of the Mental Health Crisis Team and some members of the staff including Mr. Mewburn and Ms. Hillhorst. It may not be the role of Ms. Napier, as a member of the Mental Health Crisis Team, to pass on substantial detail of information obtained by her during such an incident, but it is clear that information of this type, however obtained, must be critical to the proper care and supervision of a person in custody either at Quamby or elsewhere.

I am not able to say on the evidence what information Ms. Napier passed on but it would seem clear that if any information was passed on then it did not seem to have any impact upon the management of Mark Watson. It certainly does not appear to have come to the attention of any of the staff at Quamby, including management who became involved in the management of Mark Watson after this time.

It is also of interest to note that the evidence of Dr. Westcombe indicates that he had a discussion with the Mental Health Crisis Team. It is not clear what the terms of that discussion were and whether it went beyond the making of arrangements for the examination by Dr. Westcome but if the discussion involved details of the type contained in the report prepared by Ms. Napier then this material may have influenced Dr. Westcombe in relation to the decision that he made concerning the non-admission of Mark Watson.

It is also significant that Ms. Napier was advised by the supervisor that Mark Watson had been discovered on a routine 15 minute check. This does not accord in any way with the evidence as it is clear that he was discovered as a result of Ms. Rowan deciding to carry out an inspection at a time when she was not required to carry out an

inspection. As I understand the evidence Mark Watson was not on 15 minute observations at that time but only on normal observations of 30 minutes.

I would recommend that there be a protocol developed between Mental Health Services and Quamby whereby in circumstances where the Mental Health Crisis Team attend at Quamby that a detailed report be provided immediately by the Mental Health Crisis Team concerning any information that they obtain from the detainee concerning matters pertaining to the safety of the detainee.

RICHARD GEORGE YOUNG Mr. Young was the manager of A.C.T. Youth Justice Services as at the 16th of September 1996. He was the immediate supervisor of the person who held the position of manager of the Quamby Youth Detention Centre. As mentioned previously the on call manager who at the relevant time was Ms. Hillhorst was also directly responsible to Mr. Young. The arrangements to the on call manager were that they reported directly to Mr.

Young. By reason of this situation Ms. Hillhorst attended upon Mr. Young on the morning of the 16th of September.

Mr. Young indicates that he was given some details of the incident by Ms. Hillhorst but was not precisely clear in his memory of the nature of those details. He indicated (Transcript 23.10.98, page 46) that "My understanding was that he was sitting on a shelf and that she (Jayne Rowan) - well, my understanding of that was that she put her arms around him and held him." He was of the view that this was more in a comforting gesture than a lifting or restraining gesture. He indicated that he had not spoken to Franc Woods but only to Lynette Hillhorst and following the discussion it was decided that the matter should be relisted at court as soon as possible with a view to having Mark Watson taken to hospital. He had no recollection of seeing any incident reports at that time in relation to the matter but accepted that incident reports would generally find their way down to him.

He accepted that he had not himself carried out any investigation of the unit nor any investigation into the circumstances of the attempted hanging. He indicated (Transcript 23.10.98, page 45) that he now accepted it would have been a very useful exercise for some inspection to have been carried out in the unit.

He indicated that he had spoken to Jayne Rowan on the Monday but had not spoken to Charlie Shore for some days.

It is very unclear from Mr. Young's evidence as to what information, if any, he obtained from Ms. Rowan or Mr.

Shore concerning their understanding of the events of the 15th of September 1996. He indicated from time to time that Ms. Rowan was very upset and that perhaps they hadn't gone into very much detail about the incident because of his concern about her being upset. It would seem to me to be fair to say that Mr. Young was less than forthcoming in relation to his memory of his understanding of what he had been told by anyone concerning the events of the 15th of September. I will come in due course to a more substantial assessment of Mr. Young but will indicate at this stage that whatever he knew the only action he took was to support the decision already made by Ms. Hillhorst that Mark Watson had to be taken back to court and also to hospital. Apart from this he seems to have taken no action nor directed that any action to be taken in relation to any other investigation into the circumstances surrounding the incident of the 15th of September.

It is clear that his role was as the person who was ultimately responsible for the proper care and safety of Mark Watson and by his failure to cause any investigations to be made he failed in that responsibility. I might also say in passing that the system, which I will return to in due course, which required the on call manager to report directly to Mr. Young was entirely inappropriate. The direct responsibility for the well being of detainees must always rest with the manager of Quamby and only ultimately with Mr. Young as the supervisor of that manager.

To allow a situation to develop in which the actual manager, in this case Mr. Woods, was not a party to any discussions concerning the circumstances of Mark Watson and the incident the of the 15th of September was extraordinary. Such a confusion of responsibilities between Mr. Young and Mr. Woods inevitably led to problems in which no one knew what was going on and no one was able in those circumstances to properly carry out their responsibilities. If Mr. Woods had become involved and had been made more aware of all of the circumstances he may have been able to make a more appropriate response than he did. Mr. Young seems to be in a position where he had to be told, but having been told, seemed not to be of the view that he had any responsibility in relation to any investigation to ascertain why an event which everyone seemed to accept ought, or could not have happened, did happen.

As mentioned above Mr. Young indicated that he did not believe he had seen any incident reports and in particular denied having seen any report from Ms. Hillhorst. For the reasons outlined above, I am prepared to

accept that Ms. Hillhorst did supply such a report to Mr. Young. As to where it went is, of course, a mystery. Mr.

Hertel gave some evidence possibly about this document and I will refer to this in due course.

Mr. Young, having participated in the decision making of the 16th of September 1996, appears to have taken no further action in relation to Mark Watson during the course of the period until his ultimate hanging. It is clear, however, that he was kept aware of at least some of the developments and indicated that he was aware that Mark Watson had returned to Quamby on the afternoon of the 16th but it is also clear that he did nothing after receiving this information.

FRANCIS PARATA WOODS Mr. Woods was the acting manager of the Quamby Youth Detention Centre as at the 15th of September 1996 and had held that position since the 12th of August 1996. His evidence indicates that he has no real memory of being present at the meeting between Mr. Young and Ms. Hillhorst. He had been contacted at home on the evening of the 15th by Mr. Mewburn and then subsequently by Ms. Hillhorst. There seems also to have been a possibility that he was later contacted by Ms. Hillhorst who advised him of the results of the Mental Health Crisis Team visit and the decisions that had been made as to the future activities involving Mark Watson. He indicated that he did not recall how he had become aware of the fact but he was aware of the fact that a drawstring from a track suit had been involved in the attempted suicide. He had never been told anything about shoelaces. He also indicated that he believed Mr. Mewburn had told him that the cord was attached to a shelf by way of a knot. He gave evidence that he was surprised that this was so because he believed the shelves were fitted securely to the wall and that there was no gap. He was not aware of any earlier problems in relation to the shelves. He accepts that Mr. Mewburn called him as a courtesy and that Mr. Mewburn was only required to call the on call manager.

Mr. Woods indicated that he directed Mr. Mewburn to call the Mental Health Crisis Team but did nothing else. Ms.

Hillhorst only passed on to him her observations and he gave her no directions.

He specifically indicated that he gave no instructions to Mr. Mewburn or Ms. Hillhorst about preparing incident reports as that was standard practice and they would be prepared without any such instruction.

He indicates that on the morning of his return to work, the 16th of September, he rang the people who had been working the night before and organised a critical incident debriefing for them on the Wednesday afternoon. He rang them to inform them of this. He indicates that he spoke only briefly to them, particularly to Ms. Rowan, who was upset. He does not recall getting any further details from Ms. Rowan relating to the incident and that the only details he had were from the supervisor and Ms. Hillhorst. He did not recall seeing any documents concerning the matter on that morning.

He was asked a specific question in relation to the role of the on call manager which in many ways encapsulates the problems which occurred in relation to the response of the staff and management at Quamby to the incident of the 15th of September 1996.

"What is the usual practice for the on call manager as far as briefing the manager for the next day?---When you are talking about the manager, you are talking about Richard Young or are you talking about me." (Transcript 2.11.98, page 105).

He went on to reiterate that the practice was that the on call manager didn't contact him as the manager at all but reported directly to Mr. Young. The case was that even if he was the on call manager he had to report to Mr.

Young.

He went on to indicate that while he didn't believe this was a problem it could create a difficulty in relation to the transfer of information as particularly on a Monday morning there would be a delay by reason of work load in allowing him to contact Mr. Young. He indicated that frequently on Monday's a meeting would not occur until the afternoon. He did not recall attending the meeting with Mr. Young and Ms. Hillhorst but recalls specifically that he was not present at any meeting that involved Mr. Hertel, Mr. Young and Ms. Hillhorst. He said in evidence that he was not surprised that he was not included in that meeting as a decision had to be made quickly and it was the type of decision that could be made without any involvement from him.

He accepts in his evidence that as a result of his state of knowledge on that morning, including the decision that would be made at the meeting between Mr. Young and Ms. Hillhorst, he had an expectation that Mark Watson would be admitted to hospital. He knew that Mark Watson was being taken before the court but was unable to recall how he obtained that information.

He was aware that a cord had been used and he knew it had been slid up behind the shelf and tied in a knot. He was not aware how the cord had been removed. He knew nothing about the need to obtain a cutting implement and knew nothing about the attendance of Mr. Towhidi at the unit. On balance it would be fair to say that he was aware of very little of the details and accepted that he did not go into the details because "I knew Mark was taken to hospital, I wasn't expecting him to come back that day". Indeed the evidence clearly indicates that Mr. Woods left the centre during the morning and did not return at all that day.

It seems that at that time he was engaged in a substantial activity involving the recruitment of staff and it might be fair to say that the impression one would gain from his evidence is that that was his particular role at Quamby at that time. I accept that he was the manager but the only occasion during his evidence in which he showed any degree of animation was when he described his role as the recruitment officer and his evidence in relation to the training of such people. It is clear from the evidence that he took no part in any decision making process that occurred that day; that he caused no inquiries to be made in relation to how the incident involving Mark Watson had occurred; that he removed himself from the centre in accordance with his activities and was not aware of the return of Mark Watson to the centre that day.

This situation occurred largely as a result of the peculiar position in which Mr. Woods found himself at that time.

That is to say that he was only the acting manager, that he'd only been there for a short number of weeks, that he was not familiar with the operations of the centre; and was unaware of some of the operations of the centre, that the on call manager was required to report directly to Mr. Young and not to him and that as a result of this he was excluded from any discussions which would have increased his knowledge of the catastrophe that was awaiting the return of Mark Watson to Quamby. While one has great sympathy for Mr. Woods' position of inferiority to Mr.

Young it is clear that he carries a direct responsibility in his failure to cause any inquiries to be made in relation to the circumstances of the hanging as any cursory examination of the unit would have disclosed the presence of the potential hanging point which was initially used by Mark Watson on the 15th and again used by him, fatally, on the 17th of September.

RUSSELL EDWARD HERTEL Mr. Hertel was employed as a psychologist with Youth Justice and based at the Quamby Youth Detention Centre.

Mr. Hertel indicated that he had attended at the meeting between Mr. Young and Ms. Hillhorst and his recollection was that he had come somewhat late. He was aware only of the fact that Mark Watson had attempted suicide that evening because he had been advised in the morning in the control room. He indicates that he went up and spoke with Mark but there is no real evidence concerning that discussion. It was subsequently agreed that he would be part of the group who took Mark to court and that he would have the responsibility to take Mark to the hospital.

He indicated also that at the end of the meeting it was the view of those at the meeting that there was a general expectation that Mark Watson would be admitted to hospital.

Mr. Hertel gave some evidence concerning a document which he may have received at the conclusion of the meeting between himself, Mr. Young and Ms. Hillhorst. He did not have a clear recollection as to what the document was and had a less than clear recollection of what he did with it. He seemed to have the same difficulty in relation to whether he had received any documents from Ms. Hillhorst to return to Quamby after the court appearances.

He attended at the court with Ms. Hillhorst and then attended at the hospital. He had a discussion with Dr.

Westcombe and it appears from his evidence that he had hoped that his presence would ensure that Mark Watson was admitted to hospital. This did not occur.

Mr. Hertel's role in relation to a response to the events of the 15th of September seems only to be that he was drawn into the meeting at the last moment to facilitate the transfer of Mark Watson to court and to the hospital as Ms. Hillhorst was not able to do this as she had to remain at court. Mr. Hertel finally attended the hospital with another worker, Mr. Plewa, and returned Mark Watson from the hospital to the court and then saw him again back at Quamby.

SECOND VISIT TO THE CANBERRA HOSPITAL The incident of the 15th of September 1996 led to Mark Watson attending at The Canberra Hospital. The crisis workers informed Dr. Westcombe at the hospital that Quamby staff would be contacting him for an appointment.

This occurred and Mark attended at The Canberra Hospital in company with Mr. Hertel and Mr. George Plewa, a case worker from the Youth Justice Community Unit.

Mark was examined by Dr. Westcombe who had admitted him to the hospital on the earlier occasion in July 1996.

Dr. Westcombe in his evidence indicates that he recognised Mark when he came in in September as the same young person whom he had dealt with in July and that he had access to the notes that he had taken at that time.

He further indicated that he received additional information in September from the staff at Quamby and also from the Crisis Team. It is not clear from his evidence as to what precise information he received concerning the circumstances of the incident of the evening of the 15th of September. His evidence was in the following terms: (Transcript 11.11.97, page 15) "I certainly was presented with information which suggested that he appeared in a position which - I mean I know this sounds convoluted but I mean I don't think one can assume necessarily that because he was found with a cord around his neck that . . . I've lost track of the question. I mean your using the word suicide and I think . . ." The impression I gain from his evidence is that he did not seem to be prepared to concede that he was told about the circumstances of the discovery of Mark necessarily indicated to the doctor the he was attempting suicide on the evening of the 15th of September. This, perhaps, suggests that he did receive some detail from Ms. Napier in relation to her discussions with Mark Watson on the evening of the 15th of September.

The doctor indicated (Transcript 11.11.97, page 16) that his initial response was that it was likely that the young person would be admitted and that he had contacted the Sister responsible for bed allocations to indicate that fact. He was then asked: (page 16) "Why didn't you admit him?---Because based on my assessment and after discussing it with Dr. Hughson we decided that it was not appropriate at that time." He continued as follows: "Because I did not believe from my assessment that he was suffering with a mental illness or a mental disorder.

He did not appear to be depressed which actually I was somewhat - because I did remember him I was somewhat surprised about having remembered how he appeared the previous time I'd seen him and he certainly did not appear to be depressed - anything like that. He did not appear to be depressed at all." He indicated that he rang Dr. Hughson because Dr. Hughson was the duty psychiatrist on that date and if Mark was to be admitted he would have to be admitted under Dr. Hughson's care. It appears that when Mark was admitted in July he was similarly admitted under the formal care of Dr. Hughson notwithstanding that Dr.

Hughson had not seen him at any time.

The doctor was content that the assessment that he made on that day was more than adequate for the purposes which he was undertaking at that stage.

The doctor conceded that he accepted that Mark was very unhappy at the prospect of returning to Quamby and that his attitude changed when he was advised that he would not be admitted to hospital. Dr. Westcombe was of the view, however, that notwithstanding this unhappiness he was not able to detect anything that suggested to him that Mark was at risk of suicide. He accepted that his understanding of Mark's circumstances at that time meant that it was inevitable that he would be returned to Quamby.

Following the assessment he wrote a letter which was delivered to the Court in which, amongst other things, he described the actions of Mark Watson as "a manipulative attempt to get out of custody". The doctor during his evidence indicated that he accepted that this terminology was inappropriate and that he regretted having used it.

He was, however, still of the view that notwithstanding inappropriate language that he was not wrong in describing the behaviour in those terms.

He was asked the following question by Mr. Buddin: (Transcript 11.11.97, page 23) "Well, let me put this to you. Is it possible that you were totally wrong about describing his behaviour as a manipulative attempt to get out of custody?---I don't believe so." Dr. Westcombe noted:(Transcript 11.11.98, page 24) "I thought that he was still at some risk if he was returned and that's what, you know, the monitoring was still in place when he went." Dr. Westcombe maintained the position throughout his evidence that he did not believe that he made a wrong diagnosis or decision in relation to Mark, but indicated that if a situation similar to that which confronted him on that day occurred again he would deal with the matter differently. He went on to indicate that he would deal with it differently because he had found the stress of the events of the death of Mark Watson and their sequel very difficult to cope with and that he was not as he stood in the witness box on the 11th of November 1997 prepared to put himself into that position again. His answers in response to this line of questioning clearly indicate that he still adhered to his original decision notwithstanding the impact that its consequences had had upon him and others.

He was asked the following question in summary by Mr. Buddin: (Transcript 11.11.97, page 37) "In other words what you would if it was down to you is admit even though you would regard it as clinically an inappropriate thing to do?---Yes, I would do that. That's exactly right." The position of Dr. Westcombe is perhaps best summed up by an answer he gave to Mr. Bradfield: (Transcript 11.11.98, page 48) "Well I thought my brief was, if you like, was mainly to work out whether admission was warranted. And I thought that admission would have been warranted if there was evidence, for example that he was depressed, and that admission management in a psychiatric institution would have been of some purpose. And getting the information that he was not actively suicidal and was certainly supportive of that as well." He went on to say follows: (Transcript 11.11.97, page 49) "One of the issues is admitting - do you admit someone if you think they will be suicidal because they're incarcerated or not, or do you only admit people when they've got a psychiatric illness, and there's this issue of suicidality around it." The end position of Dr. Westcombe was, as I understand his evidence, that he was only able to admit people to the psychiatric unit if they suffered from some form of psychiatric illness. He had admitted the young person to the unit in July because at that time he held the view that the young person was suffering from depression in addition to the fact that that he had no proper accommodation. On the second occasion in September he was not convinced that the young person was depressed and it was clear on the evidence that the young person had accommodation, however unsatisfactory, at Quamby. This change in circumstances is the basis, as I understand the evidence of Dr. Westcombe, for his decision not to admit Mark on that day and as a result of that decision he was returned to court and remanded in custody to Quamby.

THE RETURN TO QUAMBY The control room log indicates that Mark Watson returned to Quamby at 2.55 p.m. on the 16th of September

1996. Upon Mark Watson's return to Quamby, he being transported by the police, he was placed in the search room near the control room. As indicated by the control room log it was near shift handover time. It appears from Mr. Hertel's evidence that Mark Watson remained in the search room for some time and that the delay was long enough for Mr. Hertel himself to go and make some observations of Mark. Mr. Hertel indicates that he checked Mark several times and then rang up and asked someone to come and move him.

He indicates that he gave no specific instructions to any of the workers as to how they ought deal with Mark Watson and seemed to assume that they would understand what was needed to be done. He didn't ring the six bed unit or go directly there to indicate to anyone anything about the results of the visit to the hospital or to provide any specific instructions. He indicates in his evidence that Mark Watson was to be on 5 minute observations. He further indicates that he made an instruction or a recommendation to that effect later on that day. It is clear that Mark Watson had been on 5 minute observations following his attempted suicide which

commenced at about 10.15 on the 15th of September and that these had continued until his departure at about 9.45 a.m. according to the control room log of the 16th of September. His special observations resume, according to the special observations book, at 3.30 p.m. when he was returned to room 605. The observations appear to have been conducted by Mr. Dugan.

Mr. Hertel indicates that he didn't give any instructions as to where Mark Watson ought to be kept but accepted the situation would still be that he remain in the special needs unit. He was asked the following questions (Transcript 30.10.98, page 55): "And you didn't think to go and tell them about the fact that he was even back from the hospital, had been refused admission, and that he was a very, very vulnerable time?---We would have had a briefing before the shift came on and that information should have been passed on at that time?

By whom?---I would have thought by the handing over shift supervisor or on myself.

How were they to know? The information that you had - you had unique information at that point in time. You'd been to the hospital. You'd spoken to the doctor. You'd been with the young fellow during the course of the day and seen how he'd conducted himself. And you didn't pass that on to anyone?---No. I would of thought that I'd pass that on to the shift supervisor when I came back from court.

What, just orally?---Mm.

Well was that the shift supervisor for the shift that was going off or the shift supervisor for the one coming on?---It should have been the shift supervisor who was going off.

So that you depended on that person passing on whatever it was that you knew?---To my knowledge that would have been right.

He was asked a number of questions in relation to an observation he had made in the induction room when he had observed Mark Watson putting both his hands around his neck indicating a choking motion while speaking of self harm. He indicated that this had been a passing gesture which he had observed and he did not believe that Mark Watson had seen him observe it. He did not regard it at that time as being particularly significant and did not pass that on to anyone.

Later that day Mr. Hertel wrote the psychologist's recommendation, exhibit 66, which contained the springtime in Quamby comment. It is clear from his evidence that this recommendation did not come to the attention of staff prior to the death of Mark Watson and was the subject of some gratuitous comment by Mr. Barnwell. The recommendation was put under the door for Mr. Woods to approve prior to its release. Mr. Hertel indicated that he did this because he was not as yet sufficiently confident in his relationship with Mr. Woods to issue such notices on his own initiative. He indicated that he had done so with other managers but had not done so with Mr.

Woods. It appears that this recommendation became controversial when it ultimately appeared on the manager's instruction book.

Mark Watson was removed from the search/induction room and placed in room 605, the same room that he had occupied during his recent stay at Quamby.

There is, of course, no documentary evidence to indicate what, if anything, Mr. Hertel passed on to the shift supervisor. The shift supervisor for the B shift who would have been on duty at the time Mark Watson returned to Quamby on the 16th was Mr. Hess who handed over to Mr. Mewburn. It is of interest to note in the handover sheet, presumably prepared by Mr. Hess, the comment appears "Mark Watson bailed". On the handover sheet, presumably prepared by Mr. Mewburn, that fact is disputed and the following comment occurs "Mark Watson is not bailed. He is now remanded til 26.10.96. Mark is suicidal and needs to be watched closely. Five minute obs while in his room. He has already tried to commit suicide." This is the sum total of any documentary evidence relating to Mark Watson and the events of the 15th and 16th of September. One assumes that they represent a brief summation of the material provided by Mr. Hertel to Mr. Hess (the shift supervisor who would have been "going off" at the end of the B shift) who then orally transferred it to Mr. Mewburn. If, however, it is correct that Mark Watson returned to Quamby at about 2.55 p.m. it is possible that Mr. Hertel did not speak to Mr. Hess as he perhaps implied but to Mr. Mewburn. The shift handover sheet for the 16th of September B shift indicates that Mr.

Hess was the shift supervsior for that particular shift. The normal shift routine would indicate that Mr. Hess would have remained on duty until 3.00 p.m. when he would have handed over to shift C which the shift handover sheet indicates was under the control of Mr. Mewburn. However, a perusal of the control room log for the 16th of September indicates that Mr. Mewburn came into the centre at 12.45 and that he assumed duty from Mr. Hess at 1.00 p.m. He continued on duty at the 3.00 p.m. handover when there is a further entry reflecting, in effect, a shift

handover and the listing of the various staff members on duty as part of the C shift for that day. It therefore appears from the control room log that Mark Watson returned to the centre on a shift under the control of Mr.

Mewburn and if any communication took place between a shift supervisor and Mr. Hertel then it appears it had to be with Mr. Mewburn. This may be reflected in the entries on the shift handover concerning Mark Watson's status which were entries made on the evidence by Mr. Mewburn.

On the C shift of the 16th of September the control room log indicates that Mr. Tootel and Mr. Dugan were assigned to the six bed unit. It is of interest to note that the shift handover sheet for the C shift on the 16th does not contain any information as to who was on duty other than Mr. Mewburn and Ms. Richardson. This is another example of the failure by Mr. Mewburn to properly keep records as required in his employment.

Mr. Dugan gave evidence that he and Mr. Tootel had taken Mark up to the building when they started their shift.

He subsequently moved away from that position and indicated that he didn't remember taking Mark up to the six bed unit at all. He did not recall having any conversation with, or seeing, Mr. Hertel at the centre that day. He gave evidence that he thought he was aware that Mark was on 5 minute observations and presumed that his supervisor would have told him that. He had no recollection of any conversation concerning that and did not recall seeing any documents relating to the observations.

The special observation book indicates that Mr. Dugan conducted 5 minute observations on Mark Watson commencing at 3.30 p.m. and continuing until 10.00 p.m. The observations after 10.00 p.m. purport to have been made by Mr. Barnwell. I will say more about this in due course.

It was suggested to Mr. Dugan that he had not done the 5 minute observations as required and he conceded (Transcript 13.10.98, page 76) that this may well have been the case.

He was shown a question from his record of interview with the police which indicated that he had spent about 20 minutes sitting in the room talking to Mark Watson. He was not able to show in the special observation book where this might have occurred and conceded that the special observation book had no recording of any such event.

It is not necessary at this time to go into detail into Mr. Dugan's evidence other than to suggest that it is clear that the entries made by him in the special observation book cannot be relied upon as accurately reflecting what was occurring. This is particularly so as there is some evidence to suggest that an incident occurred during the course of the evening which resulted in Mr. Tootel leaving the centre. There is nothing in the special observation book to reflect that particular incident which, although it did not involve Mark Watson, would clearly have caused difficulty in relation to the 5 minute observations and the accurate recording of them by Mr. Dugan.

Mr. Dugan was no longer employed at Quamby as at the date of giving his evidence.

NEIL KEVIN TOOTEL Mr. Tootel gave evidence that he had gone to the search room at the commencement of his shift and that he had taken Mark Watson to the six bed unit. He indicated that he had been told that Mark Watson was upset and that he was to be taken to the six bed unit. His memory was that he did this with Mr. Dugan. He also indicated in his evidence that he had received a general instruction relating to all persons in the six bed unit to indicate that he had to observe them and try and calm them down. This instruction he accepted also included Mark Watson. His memory was that he could not recall at the date of giving evidence what form of regime of observations Mark Watson was on but accepted that the evidence was that he was on 5 minute observations.

He indicated that he was not aware of the attempted suicide on the 15th of September. He could not recall any conversation with Mr. Hertel and could not recall if he had seen him in the waiting room area or in the control room area.

Mr. Tootel indicated that it was his memory that he and Mr. Dugan had walked Mark Watson up to the six bed unit at about 2.45. This was before they were to commence their shift. He was unable to explain the non-starting of the observations until 3.30 p.m. if that was the correct timing. I would have to note that the control room log clearly indicates that Mark Watson did not return to the centre until 2.55 p.m. which is more consistent with the evidence of Mr. Hertel. It would seem on balance that the correct sequence of events is that Mark Watson arrived at Quamby at about 2.55, that he stayed in the search/induction room for a period of time sufficient to enable the shift handover to occur and that he was then walked up to the six bed unit by Mr. Tootel and Mr. Dugan close to 3.30.

He was asked a number of questions concerning the incident earlier referred to and to which I will return in due course, but it is clear from his evidence that he was less than forthcoming about this incident and had little memory of the events of the 16th of September. The control room log indicates that he left the centre that evening at about 8.00 p.m. There is no evidence to suggest that he was replaced upon his departure which would have left Mr. Dugan in charge of the six bed unit.

It would seem in the circumstances that insofar as one is able to form any concluded view about the return of Mark Watson to Quamby it appears that he returned at about 2.55 p.m. and stayed for some period in the search/induction room and was then walked up to the six bed unit by Mr. Tootel and Mr. Dugan. The 5 minute observations which had been ordered by Ms. Hillhorst on the 15th of September either continued or were by inference recommenced following the return to Quamby as reflected in the shift handover sheet. The conducting of the observations and their recording in the observation book by Mr. Dugan is not reliable, but it is clear that nothing untoward occurred to Mr. Watson during the conduct of the C shift for the afternoon and evening of the 16th of September 1996. The end of the B shift for that day saw the commencement of the A shift for the 16th of September at which the senior youth worker was Mr. Baker and the two other workers were Mr. Barnwell and Ms.

Dillon.

INCIDENT WITH DETAINEE L.

Mr. Tootel in his evidence made comment about an incident which he said involved himself, Mr. Dugan and detainee L. in the six bed unit on the 16th of September 1996. He indicated that as a result of this incident he had sustained some damage to his glasses and also possibly some physical injury. The incident included a suggestion that Mr. Tootel and Mr. Dugan were enclosed in a unit with detainee L. by other detainees. There were elements of violence involved and it was suggested that it had taken some 15 to 20 minutes for the whole incident to be completed. Mr. Dugan had no memory of this incident nor did Mr. Mewburn, the shift supervisor. It is not necessary for me in the circumstances to form any views concerning the particular incident. The only relevance of the incident to this inquest is that if it did occur, which may be in dispute, then it clearly was not in any way reflected in the special observation book.

There was a lack of documentary evidence at all other than documents prepared in relation to a claim for compensation by Mr. Tootel. It is suggested that the incident occurred some time prior to 8.00 p.m. as that is the time that Mr. Tootel left the centre. There is nothing in the special observation book between 3.30 p.m. and 8.00 p.m. to indicate that Mr. Dugan was involved in anything other than observing Mr. Watson every 5 minutes and recording those observations. The significance of the incident is the picture that it might paint of the accuracy of the special observation book.

There is ample direct evidence from other sources and other circumstances that clearly indicate that no confidence can be placed in the special observation book. There are errors and omissions and lies contained in the special observation book and it is necessary that if this system is to continue that there be a regime that requires the book to be accurately maintained and that those who keep it are to know that it will always be inspected by their superiors and errors dealt with appropriately.

EVENING OF THE 16TH/17TH SEPTEMBER 1996 The situation that existed at the handover from the C shift of the 16th to the A shift of the 16th which would continue into the 17th of September 1996 was that Mark Watson had returned to Quamby after an attempted suicide and after having been refused admission to the hospital. He was returned to the same room that he had occupied at the time of his first attempted suicide. No inspection had been made of this room by any person to ascertain whether there was a capacity within that room for someone to hang themselves. The evidence available to this inquest would indicate that any inspection based upon the knowledge held as at the 16th of September would have clearly and easily revealed the presence of the potential hanging point, namely the gap between the shelf and the wall in room 605. Such inspection had not occurred. There was clear evidence that Mark Watson was suicidal. Comments had been made by him both to Mr. Hertel and Ms. Hillhorst and also earlier to the Mental Health Crisis Team. This ought to have put people on notice of his ongoing unhappiness.

It appears clear from the evidence that the steps taken by management and staff at Quamby represented the highest level of care that could in theory be made available. That is to say that Mark Watson was placed in what was regarded as the safest and most secure area of the institution and subjected to the most rigorous observations, namely every 5 minutes. One would assume that an institution of the type of Quamby would not be able to provide any greater degree of safety for a resident than was in theory provided on this occasion. The fatal flaw in this system, regrettably, is that it must be carried out by persons employed to do a particular job. Not only did those employed to do the job fail in their duty to carry out a proper inspection and remove, following that inspection, the potential hanging point, but more significantly those who were required to perform and supervise the 5 minute observations failed in their responsibility.

While no problem arose during the time of the observations carried out by Mr. Dugan it is clear on the evidence that they were not properly conducted or recorded. Regrettably the observations carried out by Mr. Barnwell, who came on duty as part of the A shift for the 16th of September 1996, were also not carried out properly and the failure to do those observations and, more importantly, the presence of a confused situation in relation to the end and beginning of shifts led to the ultimate tragedy of the death of Mark Watson.

It is necessary to consider in some detail the activities of Mr. Barnwell and others involved in the A shift on the 16th/17th of September and also the activities of some of the persons involved in the B shift for the 17th of September 1996. The critical problems in relation to the death of Mark Watson arise partly as a result of the failure of Mr. Barnwell but also partly as a result of the inherent corruption of the system which had occurred over a long period of time and in relation to which I have already made some comments, but will make further comments in due course.

The A shift of the 16th of September 1996 consisted of Mr. Daniel Mark Baker, who is no longer employed by Quamby, as the senior youth worker. The evidence indicates that A shifts are constructed differently from the B and C shifts in that there is no person specifically described as a shift supervisor but that that role is performed by a senior youth worker. As a general rule there is only one other staff member on duty for an A shift, but where there are special observations to be carried out as there were on the evening of the 16th/17th of September then a second staff member is called in, making a total complement of three. The system operates on the basis that the senior youth worker, in this case Mr. Baker, remains for the whole of the shift in the control room, one of the youth workers, in this case Mr. Barnwell, is responsible for the observations in the six bed unit and stays for the whole of the shift in that unit and the third member of the team, another youth worker, in this case Ms. Dianne Dillon, carries out 30 minute observations of all residents and also has a role in generally observing the grounds and environment of the centre.

DANIEL MARK BAKER Mr. Baker indicated in his evidence that he was a youth worker with a permanent position and had been employed at Quamby as at the date of the death of Mark Watson for almost three years.

Mr. Baker indicated that upon commencing duty that evening he was aware of the situation involving Mark Watson principally from material contained on the white board in the control room. This board indicated that Mark was suicidal and on 5 minute observations. It was for this reason that a third staff member had been brought in.

This arrangement is made by the shift supervisor for the previous shift, in this case Mr. Mewburn.

He indicated that Mr. Barnwell came in to work and offered to do the 5 minute observations in the six bed unit and Mr. Baker was happy to accept this offer. Mr. Baker indicated that Mr. Barnwell was actually senior to him and certainly more experienced. On this evening because Mr. Barnwell was on days off and not formally rostered Mr. Baker was the senior officer and as such entitled to act as the defacto shift supervisor. Mr. Barnwell apparently suggested that he could do the observations and also offered to do the medication for the residents.

This was agreed and the evidence suggests that Mr. Barnwell did a substantial amount of medication preparation during the course of the shift.

According to Mr. Baker the evening progressed uneventfully and his entries in the control room log commencing at 11.00 p.m. and concluding at 7.00 a.m. indicate an entirely uneventful evening. The control room log was subject to considerable inquiry and is clearly false. This circumstance led to a considerable discussion with Mr.

Baker and others concerning the so-called early on early off regime. I will return to this concept again in more detail but it is necessary to make some preliminary comments concerning it in view of the events of the early morning of the 17th of September 1996.

Mr. Baker's position seems to be that in all the time he had worked at Quamby there had been an acceptable procedure whereby staff for the next shift arrived a half an hour, or in some cases more, before the time of the official start of the shift. This practice had developed, it seems, to enable those persons on the outgoing shift to leave early. It is difficult to glean from all of the evidence the actual purpose of this procedure but there seems to be an impression that it was perhaps first developed for the benefit of the night shift staff so that they might leave earlier in the morning than they were entitled to do in accordance with their terms of employment.

The strict legal situation is that staff members on the A shift commenced work at 11.00 p.m. and stopped work at 7.00 a.m. A perusal of the documentary records, particularly the control room log and the special observation books, reveals a pattern in which this timing was not adhered to by at least some of the staff. I am not able to conclude at this time that this early on early off regime was a procedure approved of, or indeed known of, by those in senior management but the inference is suggestive that it was so long standing and so wide spread that it would be difficult to understand how people, particularly Mr. Young, were not aware of its operation.

It did not as a general rule impact upon the operation of the centre in that the system seemed to operate on the basis that no one left until someone was there to replace them but it had caused a corruption of the system which led almost inevitably to the type of circumstance that occurred on the morning of the 17th of September 1996.

At this point in time I would comment that as far as Mr. Baker was concerned he clearly operated on the basis of the early on early off principle and notwithstanding evidence that I will turn to shortly I am content to accept as a fact that he had left the control room and gone home well before 7.00 a.m. The control room log, of course, indicates that at 7.00 a.m. he handed over duties to Mr. Withers. This is clearly not so and Mr. Baker accepts that it is not so and indicates that it was a well known practice that one put false entries in the control room log relating to departure times at least of some staff at shift handovers.

Mr. Baker is not able to provide any information concerning the precise activities from 6.30 a.m. onwards that one could accept. It is clear from his evidence, as corroborated by others, that well before 7.00 a.m. he had rung Mr.

Barnwell in the six bed unit to tell him to go home. He did this following the arrival of Ian Sherer. Ian Sherer declined to attend at the six bed unit and there appears to have been a dispute between Mr. Sherer and Mr.

Baker concerning Mr. Sherer's attendance at the six bed unit. Subsequently Mr. Baker rang a second time when he observed that Mr. Barnwell's car was still present in the centre and told him to go home. He recalls that Mr.

Barnwell told him that he couldn't go because Mark Watson was awake. Subsequent to these conversations Mr.

Baker left. His evidence is that he left about ten to seven. This evidence is clearly wrong as there is incontrovertible evidence that prior to ten to seven Ian Sherer had discovered Mark Watson hanging in the six bed unit and that substantial activity occurred which included Mr. Withers, Mr. Bennett and others leaving the control room area. The ambulance, on indisputable evidence, was rung at 6.51 a.m. It is therefore clear that it is impossible to accept the evidence of Mr. Baker as to his activities on the morning.

In an attempt to explain his absence at the time of the calling of the ambulance and the other activities he attempted to put the blame on a control room clock which he believed at the time of him giving evidence in court to be wrong. He and Ms. Dillon, to whom I will come to shortly, were the only two of the substantial number of workers from Quamby who made any comment about the accuracy of the control room clock. I am not on the evidence before me able to accept that there was any error in the clock. I am content on all of the evidence to accept that Mr. Baker left the control room at or about 6.30 as was his usual practice and it was a practice that he had followed for a considerable period of time. He also attempted prior to his departure to ensure that Mr.

Barnwell left prior to the end of his shift as was his and Mr. Barnwell's practice.

I have given some consideration to whether it would be appropriate to recommend that Mr. Baker be charged with perjury in relation to the evidence given by him to the inquest. I am not, however, prepared in the circumstances to recommend such a prosecution. It may, however, be useful for the Director of Public Prosecutions to give some further thought and consideration to whether on the basis of the evidence given by Mr.

Baker it would be appropriate for legal proceedings to be commenced against him.

Mr. Baker was, of course, the officer directly responsible for the safe care of Mark Watson during the course of the A shift of the 16th/17th of September 1996. It would appear on the evidence that he totally failed in that responsibility. There is nothing to suggest that at any point in time he conducted any investigation to see whether Mr. Barnwell was properly carrying out his responsibilities. During the course of the evening it is clear that Mr.

Barnwell attended upon the control room for a period which would have left the six bed unit completely unattended. Mr. Baker had within the control room a capacity through the video monitor to observe the conduct of Mr. Barnwell but his evidence suggests that he if he did do that it was in a very inadequate way. In addition he clearly encouraged Mr. Barnwell to leave his post prior to the end of his shift and participated in an argument with Mr. Sherer to attempt to force Mr. Sherer to relieve Mr. Barnwell early. This was inconsistent entirely with his responsibilities. He left his post early and his view as to the early on early off regime would seem to be shared by the entire shift that evening as Ms. Dillon also left early. There is nothing about the conduct or the role played by Mr. Baker that would cause me to view his situation other than that he was in complete dereliction of his duty on that evening and that this dereliction did at least in part flow from the corruption of the system that had occurred over a long period of time.

DIANNE JOY DILLON Ms. Dillon was a member of the A shift for the evening 16th/17th September 1996 and it was her responsibility to conduct the general observations of the entire centre. This required her to move around all of the units during the course of the evening. The procedure was that she was required to make such an inspection every half an hour.

Mr. Baker's notations during the course of the evening reflected in the control room log indicate that she did this every hour and half hour from 11.30 p.m. until 6.30 a.m. She indicates that during the course of the evening as she moved around that on at least one if not more than one occasion she observed Mr. Barnwell in the six bed unit.

She indicated that she was aware of the events of the 15th of September 1996 and that she had spoken to two staff members about it. She was not able to recall what information she had been given at the shift handover on the 16th. She had not read the handover notes but totally relied upon what she was told by Mr. Baker.

In her statement to the police she indicated that on that evening she had gone into the six bed unit and spoken to Mark Watson while he was subject to Ian Barnwell making 5 minute observations. She was pressed concerning this in her evidence but seemed remarkably reluctant to concede that that visit had occurred on the night of the 16th/17th September.

She indicates in her evidence that her memory insofar as she has one of the events of that morning was that she and Mr. Baker left at about the same time and that Danny Baker left in his car when she recalled something she'd forgotten and returned to the centre.

She also attempted to rely on the inaccurate control room clock to justify her timings of various events. As indicated above in relation to Mr. Baker I do not accept that there was any problem with the control room clock and I therefore do not accept the evidence of Ms. Dillon in relation to her timings.

She seemed to be a supporter of and adherent to the early on early off process. She was shown an entry in the special observation book for the 15th of September 1996 which indicated that she had taken over from a Mr.

Hartig and commenced doing observations at about 6.05 a.m. She denied that this represented an example of the early on early off procedure but it is clear from the general tenor of her evidence that she clearly was of the view that Mr. Barnwell was entitled to go early as he was on days off. It is clear from her evidence that she did accept the theory of early on early off and that she herself practiced that theory.

She was asked a number of questions concerning her activities immediately prior to the completion of her shift and how she was able to do the various observations that she purported to have done within the time frame allowed. Her answers in relation to this and her answers in relation to a number of questions was most unsatisfactory. Ms. Dillon was in my view a less than impressive witness who attempted to evade her responsibility in relation to the activities of the morning of the 17th of September.

I am content on the evidence that she left the centre at about 6.30 a.m. and even if I accept that she returned, which is debatable, then it is clear that she finally left the centre no later than about 20 to seven. She certainly did not see any of the activity involved in the discovery of Mark Watson and was not present when the ambulance arrived. It is clear that she was not there at that time otherwise she would have observed or been drawn into the events of the morning.

The only satisfactory explanation for her failure to recall many matters is that she was not anxious to be frank with the inquest. This was particularly so in relation to her earlier statement to the police that she had attended upon the six bed unit during the course of the evening and had spoken to Mark Watson. This is in no way reflected in any of the observations made by Mr. Barnwell in the special observation book. She was prepared to accept that she probably went in and spoke to Mr. Barnwell but not that she spoke to Mr. Watson on that night. One would have thought that it was highly likely that three people on a shift during a night would wish for obvious social reasons to remain in contact with each other during the course of the evening. This situation seems somewhat to be in dispute although such concessions as are made by Mr. Baker, Ms. Dillon and Mr. Barnwell clearly suggest that there was an interaction between them during the course of that evening.

In relation to the credit to be given to Ms. Dillon and her evidence it is of interest to note that on a number of occasions she gave answers to questions that suggested she knew as a fact something that had occurred.

Subsequent examination of these answers ultimately showed that she did not know them as a fact but that she had been told about them by someone and then accepted them as a fact. This causes some concern as to the level of contact and discussion between herself, Mr. Barnwell and Mr. Baker. She was at pains from time to time to indicate that she had really not discussed the matter with them but I must have reservations about that fact.

She was subsequently cross-examined by representatives of the parties and Mr. Bradfield, who was appearing for the mother of Mark Watson, referred her to Mr. Baker's record of interview in which he indicated that she had come into the control room during the course of the 16th/17th September and observed to him that Mark Watson had been awake. She then indicated that she had subsequently been shown the observation book which did not indicate that Mark Watson had been awake at any time during the night and she therefore assumed that her memory was faulty as to the night on which she had spoken to him.

She also gave some evidence concerning a debriefing program that occurred shortly after the incident of the 17th of September. It appears that a number of officers, including Mr. Barnwell, were present at this discussion. It seems at that discussion there was a wide ranging consideration given by those involved to the events of the morning. It is possible that a number of the matters that became fixed in Ms. Dillon's mind did so at that time.

During further examination it was suggested to her that at the time, to which I have already referred, that she replaced Mr. Hartig she had been responsible for carrying out half hour observations over the entire centre and that her carrying out the 5 minute observations had left no one to do that job she seems to have accepted that would have been so.

Her view of the early on early off procedure was explained to Ms. Tonkin on the basis that everyone did it and she believed that both Mr. Woods and Ms. Dabin would have known about it but she was not sure about Mr.

Young.

IAN WILLIAM BARNWELL Mr. Barnwell was the person entrusted with the conducting of the 5 minute observations on Mark Watson on the A shift on the 16th/17th of September 1996. Mr. Barnwell gave evidence on two occasions and on the first occasion in November 1997 gave a substantial body of evidence relating to his view of the administration of Quamby. Much of that evidence was not pursued by reason of decisions made by me concerning the conduct of the inquest. On his return to give evidence following that decision he was less forthcoming than he had been earlier about matters generally. In relation to his activities on the 16th/17th September he indicates, as does the general body of the evidence, that he was on days off at the time he was called in to supplement the staff for the A shift so that proper arrangements could be made for the 5 minute observations. A perusal of the shift handover sheets indicates that he had last been on duty on the 14th of September, also on the A shift. He, it seems, was a regular staff member on the A shift. While he was clearly senior in rank and experience to Mr. Baker he offered to do the 5 minute observations and also the medication envelopes. At his first appearance on the 12th of November 1997 he indicated to Mr. Buddin, who was then assisting me, that he felt partly responsible for the death of Mark Watson. He further indicated that he felt partly responsible for the following reasons: "That I was not quick enough to get Mark down, that I wasn't more sympathetic to Mark when I was speaking to him and I was unable to get into his room quick enough." (Transcript 12.11.97, page 6) The evidence ultimately indicated that this was only part of the reason why Mr. Barnwell ought to have felt responsible for the death of Mark Watson. The most significant element of the need to feel responsible was that he failed to properly carry out the observations that he had been specifically employed to do on that evening. It is clear that the death of Mark Watson arose at least to a very great degree as a result of the failures of Mr.

Barnwell.

Mr. Barnwell indicates generally in his evidence that during the course of the evening he was engaged for some hours in the preparation of envelopes into which medication required for a number of days by the various residents was placed. During all of this time he continued to record, he says, with monotonous regularity all of the observations that he made during the course of that shift. A number of comments ought to be made about those observations.

The first is that he began making observations, according to the special observations book, at 10.05 p.m. on the 16th of September and that he noted the particular observations in that book. Evidence in due course indicates that these entries are false. It is clear the entries were not observations made by Mr. Barnwell, but merely invented by him when he discovered in due course upon his arrival in the six bed unit that the time entries and the name entry had already been completed by Mr. Dugan but had not been filled out as to what the observation was. The reason for this was that Mr. Dugan had availed himself of the early on early off routine and had failed to do any observations from 10.00 p.m. Mr. Barnwell for reasons of tidiness completed the observations inventing the entries contained in the remarks column. It is difficult to accept what Mr. Barnwell said about any of the observations in the book from thereon in.

The book reflects the fact that observations were conducted every 5 minutes but the reality of the situation is such that that one could not accept that this had occurred. There is some evidence that Mr. Barnwell was asleep during the course of the evening and some evidence that Ms. Dillon may have come in and observed Mr. Watson awake at a time when the entry would indicate that he was asleep. There is evidence that Mr. Barnwell went down to the control room to return the medication but there is nothing to suggest that anything was occurring other than he was gone and back again within five minutes so that the observations were continued. The most significant observations contained in the book commence at about 6.15. They observe that Mark Watson was awake, drawing at 6.15, awake at 6.20, awake at 6.25, awake at 6.30. The times thereafter for the balance of the

5 minute observations from 6.35 to 7.00 a.m. have already been written as to times and dittos under the name but no entries have been recorded as to the observations made by anyone between 6.25 and 7.00 a.m.

At the beginning of his evidence Mr. Barnwell indicated that notwithstanding its omission from his statement that he now recalled that Mr. Baker had indeed rung him twice. The, first time according to his memory, was about 6.20 and the second time about 6.25. His memory of those conversations were as to the first that Mr. Baker had indicated to him that his relief was in and he could come down. No other conversation took place. Mr. Baker hung up immediately. The second conversation was a little longer and Mr. Barnwell indicates that at that time he said he couldn't come down as Mark Watson was awake.

His evidence indicates that he was a substantial believer in and practiser of the early on early off procedure.

Mr. Barnwell returned to give evidence on the 20th of October 1998 and indicated then that he thought the first phone call was about 6.15ish. He was of the view that following the receipt of that phone call he had begun to make preparations to finish the shift and in particular that he'd washed his coffee cup and opened the front door.

He thought he may have also done some tidying up. Mark Watson, he said, awoke at about 6.15 or 6.16. He further indicates that following his awakening he was abusive towards Mr. Barnwell and swore at him. He again accepted that he had dozed off during the course of the evening while conducting the observations but there was naturally no sign of such a situation in the special observation book.

He indicated that he was aware of the incident of the 15th of September but could not recall how he had become aware of that. He couldn't recall why he had taken over from Dugan so early that evening.

He indicated that he thought the last phone call was about 6.30 so that the last phone call was before he entered the last observation in the book at 6.30 and that that was the last observation that he made. He indicated that after the last phone call and the last observation he walked out of the building when Ian Sherer was approaching the building. He indicated that he could see Ian Sherer approaching and that the door was shut. It is of some interest to compare this answer with an earlier answer made by him on the 20th of October when he indicated that he opened the front door after the first call.

It is very difficult to extract from Mr. Barnwell's evidence a clear picture of what occurred around this time. There are a number of contradictions and equivocations in his evidence. As mentioned above he has given what might be regarded as two different versions as to when the front door was open and he has given different versions as to whether he was outside the door when Ian Sherer arrived or whether Ian Sherer came into the building. He indicated at page 12 of the transcript of the 21st of October 1998 that when he saw Ian Sherer coming up the hill he opened the door and spoke to him outside. He was then shown exhibit 79 which was a statement made by him to the police on the 2nd of August 1997 in which he had indicated that Ian Sherer had come into the building.

He now indicated that he didn't recall Ian Sherer coming into the building but he does accept that after Ian Sherer came to the building it was the last time he had anything to do with anyone inside the unit. He further indicates that he believed he lit a cigarette as he was speaking to Ian Sherer. He then went on to say that his recollection was that he opened the door when he saw Ian Sherer so therefore he would have been outside when Sherer arrived. It was then suggested to him that he was actually outside having a cigarette for some time prior to Mr.

Sherer approaching. He indicated that his recollection was to the contrary.

It was then suggested to him that others had given evidence that they had seen him outside smoking a cigarette before he was approached by Mr. Sherer. He indicated that he believed their recollection was mistaken. His estimate is that he spent about a minute or two talking to Ian Sherer outside the building and that he gave Ian Sherer some information about Mark Watson, namely that he was awake and what room he was in and then left.

It was suggested to him that this might have been three or four minutes rather than one or two and he indicated he didn't know. He then went on to say that his recollection was that he saw Mr. Sherer, he did his check, he wrote it in the observation book, he saw Mr. Sherer approach, he went outside, he lit up a cigarette and had a short conversation with him.

During this piece of his evidence he indicated for the first time that he had gone to the control room during the course of the evening to deliver the medication. He could not remember seeing Danny Baker there when he went to the control room nor did he recall seeing Dianne Dillon.

He indicated that after his conversation with Mr. Sherer ended he then walked from the six bed unit to the control room which he said would take about a minute to a minute and a half. He then walked into the control room, spoke briefly to Chris Withers, grabbed his keys and walked downstairs. He did not talk long with Mr. Withers. He indicated that he had said to Mr. Withers that he would go down and start his car and then come back up and have another word with him.

It was suggested to him that Mr. Sherer did not go to the six bed unit until 6.40 or some time thereafter to which his reply was "It has been put to me before, however, I don't go along with that". He indicates that he recalls hearing the phone ringing but did not recall Mr. Withers saying anything to him. He then recalled Mr. Withers passing him on the stairs and that he, Mr. Barnwell, was in the sally port at that time and that he ran with Mr.

Withers to the six bed unit. He recalls very little about the ambulance officers and their activities.

He went in the ambulance to the hospital and when he returned he was spoken to by Mr. Woods and Mr. Young and he then prepared a written report.

It is of interest to note in relation to the incident report that he wrote out that there is an alteration made in the first line as to the time. Mr. Barnwell in that report indicates that the first call came at 6.25 a.m. and that he had done a check at 6.35 a.m. when Mark was on his bed with his legs up, he let Sherer into the room when he arrived and that he in effect spoke to him within the unit. This report represents his first written response to the events of that morning and was done before he was interviewed by the police. Surprisingly notwithstanding this early attempt to put his recollections on paper there is no entry in the special observations book at 6.35. He was subsequently asked about this absence and he indicated that he had made a mistake in the incident report because he had no access to any documents, that he was tired, that he had been through a stressful event and that it was to the best of his recollection. He ultimately accepted that his last observation had been the one written in the book at 6.30 and that he was prepared to accept if Mr. Sherer's evidence was accepted, namely that he hadn't commenced until 6.40 then there was a period of at least ten minutes during which no observations had been made at all.

He swore on his oath that he had made an observation after 6.15 and that at 6.30 a.m. Mark Watson was still alive and was not hanging.

Mr. Barnwell indicated that I should accept the fact that the observations occurred at 6.25 and 6.30 because he swore on his oath that it was true.

Mr. Barnwell presented as a somewhat complex and controversial witness in that initially in his evidence in November 1997 he was very outgoing in relation to the problems which he perceived existed at Quamby and how if there was any blame to be attributed for the death of Mark Watson then that blame was to be sheeted home directly to the system and not to him. When this line of complaint was not pursued he became in my view much less co-operative and outgoing and in many ways unreliable. As I have already indicated it is very difficult to extract out of Mr. Barnwell's evidence a clear picture of what occurred on the morning of the 17th of September 1996 but it is clear that he did not complete the observations that he was required to do under the terms of his employment, namely until 7.00 a.m. It is also impossible to accept that the entries in the special observation book reflect accurately anything that was occurring during the course of the evening. The ultimate responsibility of Mr.

Barnwell for the death of Mark Watson will be looked at in due course.

BARRY PETER HERDSON Professor Herdson is the Professor of Pathology in the Canberra Clinical School and Director of A.C.T.

Pathology. He gave evidence on the 28th of October 1998 to indicate that based upon material made available to him he was of the view that circulation had ceased in Mark Watson some time around 6.30 a.m. The effect of this view in his professional opinion was that the circulation would have stopped as a result of a constriction being applied a few minutes earlier. It is clear on this evidence that Mark Watson had hung himself a few moments before 6.30 and that by 6.30 a.m. the circulation was more likely than not stopped. This would suggest that Mr.

Barnwell had not made the observations at 6.25 and 6.30. The evidence surrounding the hanging of Mark Watson would clearly suggest that it would have taken some time for preparations to be made and in particular for the sheet to be placed behind the shelf and fixed in position prior to it being placed around his neck. I am, of course, unable to form a view as to the precise timing of these activities but it is clear, looking at the evidence of Professor Herdson, that the preparations would have involved a sufficient period of time to suggest that they had commenced at the latest by about 6.25 a.m.

CHRISTOPHER JOHN WITHERS Mr. Withers was the shift supervisor for the B shift which was scheduled to commence at 7.00 a.m. on the 17th of September 1996. He was at the time a youth worker and had been employed at Quamby for some eight and a half years.

He indicated that he arrived at work at approximately 5.45 a.m. and came into the control room at about 6.15 a.m. The control room log created by Mr. Baker indicates that at 6.30 residents checked, C. Withers in ctr. Mr.

Withers was subsequently asked some questions about this entry and indicated that in his view it was false.

Upon his arrival in the control room he participated in a form of handover with Mr. Baker and was present when Mr. Baker rang Mr. Barnwell. Mr. Withers was not absolutely clear as to whether Mr. Sherer was present in the control room when he arrived at 6.15 but accepts that it was possible and if he was not there at that time he arrived very soon thereafter. He indicates that upon his arrival Mr. Baker indicated to him that Ian Barnwell had done an overtime or night shift. Mr. Withers' memory of the conversation between Mr. Baker and Mr. Barnwell was that it had occurred before 6.30 and it involved Mr. Baker telling Mr. Barnwell that "we'll send someone up to relieve you soon". Mr. Withers indicates that when Mr. Baker got off the phone he said to Mr. Withers "Mark Watson's awake and Ian has been speaking to him". He recalls Mr. Baker saying to Mr. Sherer to go and relieve Mr. Barnwell and that Mr. Sherer indicated he would no do so. He remembers a little while later seeing Mr.

Sherer come back into the control room and he accepts that this indicated that Mr. Sherer must have left the control room following the telephone call between Mr. Baker and Mr. Barnwell.

He indicated that he recalled Mr. Baker giving him a bit of a briefing "That was fairly early on, probably until about 6.30" and indicated that he didn't recall Mr. Baker being present in the control room after that time. Mr. Withers was shown the entry in the control room duty log for 7.00 indicating that Mr. Baker had handed over duties to Mr.

Withers and indicated that this entry was also false as there was indeed no formal handing over and in Mr.

Withers' view he did not take over command for the shift as he was still in the handover phase between the two shifts. It is clear, however, that insofar as the reality of the situation is concerned, Mr. Baker was by this time gone and Mr. Withers was in control whether he regarded himself as being formally in control or not.

He indicated that he accepted responsibility in relation to directing Ian Sherer to go and relieve Ian Barnwell and that this had occurred at about 20 to 7. He indicates in his evidence that he did not specifically direct Ian Sherer to go and relieve Ian Barnwell but merely asked would he go and do it. He seems to be anxious to make the point that because it was only about 20 to 7 it was in his view inappropriate for the early on early off procedure, of which he was aware and a part of, to take place as early as it was suggested it would occur on this day.

Mr. Withers indicated that his memory of the handover between himself and Mr. Baker related only to the fact that Ian Barnwell was doing an overtime and that he was doing this overtime because Mark Watson had attempted suicide a couple of nights before and was back at the centre and was a high risk and in the six bed unit. He further indicated that this was the first he had heard of Mark Watson attempting to commit suicide. He received no further details from Mr. Baker. He had, however, read the entries on the shift handover sheets during the time when Mr. Baker was handing over to him.

He was of the view that it was probably highly likely that Mr. Sherer was not aware when he went to relieve Mr.

Barnwell of the risk that Mr. Watson represented other than that he would have known that Mark Watson was on 5 minute observations.

Mr. Withers indicated that he understood Mr. Sherer's reluctance to relieve Mr. Barnwell when requested to do so by Mr. Baker as he thought the request was too early. His view of the early on early off arrangement was that the early off regime reflected a period of 15 to 20 minutes rather than half an hour.

Following his request to Mr. Sherer at about 20 to 7 Mr. Withers indicates that he saw Mr. Sherer at a point in time where he was probably half way up the road, the driveway going towards the six bed unit. His memory is that at the time he saw Mr. Sherer, Mr. Barnwell was already standing outside the front of the six bed unit having a cigarette. He then saw Mr. Sherer go to the six bed front area where he and Mr. Barnwell stood together for three or four minutes. He went on to indicate that he was in the control room doing things and it was probably anywhere from three to four minutes when he observed that they were still there and then he saw Ian Barnwell walk down and Ian Sherer walk into the six bed unit. He indicated that he did not at the time think anything in particular of the delay that he had observed outside the six bed unit.

Mr. Withers then indicates that he recalls, vaguely, Mr. Barnwell walking into the control room and grabbing his keys or something and then leaving. Mr. Barnwell had not spoken to him during that time. His memory is that he then received the phone call from Mr. Sherer via the intercom between the six bed unit and the control room. He indicated that he thought it seemed to be a couple of minutes but it wasn't all that long between the time he had seen Mr. Sherer going into the six bed unit until he heard his voice on the intercom. He further indicated that he thought it was probably less than 20 seconds between the time Mr. Barnwell had left and the time the call was received. He appears to base these estimates of time on the fact that he caught up with Ian Barnwell in the sally port.

He ran down the stairs, the back door of the sally port was open. He saw Ian Barnwell in the sally port. He indicates that it was probably about 6.45 a.m. when he received the call from Ian Sherer. He couldn't recall whether he'd consulted a watch or a clock to form a view as to that time.

He indicates that his memory of Mr. Sherer's phone call was that Mr. Sherer had said "Get some keys up here.

Mark Watson's hanging or something to that effect". He grabbed the 16 keys out of the key cabinet and raced around to the stairwell. He yelled out to Mark Bennet and ran down the stairs. Mark Bennet was apparently in the staff room but he didn't see him at the time he shouted. When he arrived in the sally port he saw Ian Barnwell and said "Mark's trying to hang himself". His memory is that Mr. Barnwell said "I just bloody checked him".

Upon the arrival of Mr. Withers at the six bed unit he observed Ian Sherer standing at the door of Mark Watson's unit. Mr. Withers immediately unlocked the door as he was not easily able to see through the perspex. He could see something but he couldn't actually see that Mark was there. His memory was that it was daylight at that time and lights were on inside the unit. Upon entering the unit he observed to his left where the shelves were that Mark had a sheet around his neck and was hanging lifeless. He was of the view that Mark's feet were about 20 centimetres off the ground. He was shown a photograph, number 6 from exhibit 2, and indicated that Mark Watson's feet were hanging below the bottom shelf but not touching the floor.

Mr. Withers indicates that he lifted Mark up, that Mr. Sherer untied the knot and that Mr. Barnwell assisted him to lift Mark up. Mark Bennett then arrived and was assisting Ian Sherer to get the knot undone. It was apparently very difficult to move the knot and it took some time. It probably took around 20 to 30 seconds to get the knot untied. Upon the release of the knot Mark was laid on the floor. Mr. Withers checked his carotid artery for a pulse but could find none. He recalls Ian Barnwell, who was checking for a pulse in the wrists, saying "I've got a faint pulse". Mr. Withers' memory was that he replied "Well, I don't have a pulse". He could see no sign of breathing or a pulse. He indicated to Ian Barnwell "There's no pulse, let's go" and then commenced mouth to mouth resuscitation. He was of the view that it would have been slightly over a minute or so between them entering the room and commencing CPR. He instructed Mark Bennett to ring an ambulance and his memory is that Mark Bennett left promptly. CPR continued until the ambulance arrived.

The mouth to mouth CPR was principally conducted by Mr. Withers but at a point in time Mr. Bennett assisted.

Mr. Barnwell appears to have been engaged in CPR at the chest area.

Mr. Withers vaguely recalls questions being asked by the ambulance officers but does not recall making any response but accepts that he could have responded.

He indicated that Mr. Sherer did not have a key to enter the unit in which Mark Watson was residing as it was not allowed but he would have got a key at the formal commencement of the shift at about 7.00 or 5 to 7.

Following the departure of the ambulance Mr. Withers prepared, with the assistance of Ms. Masters-Smith, an incident report relating to the incident.

It is clear on the evidence before me that Mr. Withers acted at all time appropriately and is to be commended for his efforts on the morning of the 17th of September 1996.

IAN CRAIG SHERER Mr. Sherer indicated that he was a casual youth worker and as at the 17th of September 1996 had been employed at Quamby for some 8 or 9 months.

He indicated that he had arrived at work at about quarter past or twenty past six and that this was his usual practice. He was aware of the early on early off practice and seemed to be resentful of its exploitation of him because he tended to always arrive early. Upon his arrival at work he went straight to the balcony or staff room.

From there he went to the control room where he spoke to Danny Baker and was asked at that time to go and relieve Ian Barnwell. He could not be one hundred percent certain on the time but thought it was about half past six. When first asked by Mr. Baker to go he did not go. He indicated that he had a dispute with Mr. Baker and said that he "was sick and tired of being lumbered with going up and doing obs and that sort of thing because it happens with all the casuals, the permanent staff never have to worry about doing it and nine times out of ten, if I was on, I was always the first one sent up". (Transcript 15.10.98, page 87) Following this conversation with Mr. Baker he says that he left the control room and went out onto the balcony and had another smoke and a bit of a chat with someone whom he thought was Mark Bennett. He remained out there for at least five minutes, probably longer.

He then returned to the control room and seems to indicate that Danny Baker didn't realise that he hadn't gone up to relieve Ian Barnwell. This was notwithstanding the fact that Mr. Sherer had clearly indicated that he did not intend to do so. He says that Mr. Baker told him to go up there and he indicated "Well, if no one else is going to do it", grabbed his radio and started heading up.

When he left to go to the six bed unit he was aware that Mark Watson was on five minute observations but didn't recall being told anything else. He did not have a key to the unit in which Mark Watson was residing. He had no keys and would have taken the keys off Ian Barnwell. Mr. Barnwell, of course, had no key to Mark Watson's unit.

He was of the view that he left the control room sometime from 25 to to 20 to (7). He did not recall speaking to Mr. Withers before he left the control room but did remember seeing Mr. Withers in the control room before he left.

He remembered seeing Ian Barnwell as he was walking up the road, he thought he was having a smoke. He indicated that he thought it took him about a minute and a half to get from the top of the stairs in the control room to meeting Mr. Barnwell at the six bed unit. He remembered having a conversation with Mr. Barnwell outside the six bed unit but didn't remember very much about it but thought it might have taken a minute to a minute and a half.

He indicated that he himself had lit a cigarette as he left the sally port area and that he had a couple of more drags on it at the six bed unit then put it out and went inside to start his checks. He commenced his checks at cabin number one which is the first door on the left as he entered the unit and then ultimately arrived at Mark Watson's room. He couldn't see him so he turned on the blue light and looked around and that's when he found him. He thought it was still quite dark inside the cabin and when he saw Mark he "ran straight to the phone, got on to Chris Withers and told him to get up here as quick as he could". He then went and unlocked the front entry door and returned to Mark Watson's room and began yelling and banging on the door. He could not see any sign of life.

Mr. Withers arrived within 30 or 40 seconds. Mr. Barnwell was with him. Mr. Withers opened the door and they all went into the room. He observed that Mark Watson was hanging from a sheet from a shelf and that his feet were off the ground. Chris Withers immediately started CPR, Ian Barnwell was pressing on the chest and he, Mr.

Sherer, was checking for a pulse. Mr. Bennett arrived and he recalls someone went to call the ambulance. He was not sure who that was. He thought that the calling of the ambulance occurred as soon they put Mark Watson on the ground. He thought that he had put his call through to Chris Withers at about a quarter to seven but he was not absolutely sure. He thought it had taken about 30 seconds to a minute to get Mark Watson from the hanging position down to the floor. He indicated that he had a memory that upon the departure of the ambulance he had commenced with the assistance of Ms. Masters-Smith to complete an incident report but he did not think that it was ever finished as he went to the police station to make a statement to the police.

MARK GERARD BENNETT Mr. Bennett indicated that as at the 17th of September 1996 he had been employed at Quamby for about 8 months under a contract. He arrived at work that morning about 6.30 a.m. He indicated that while he was not aware of a formal early on early off regime he did know that people on the night shift would be relieved early by a worker who arrived early. It was a generosity thing in his view.

Mr. Bennett at the commencement of his evidence indicated that he wished to change a couple of things in his statement and in particular to indicate that he now recalled that after Ian Sherer had been told to go up to the six bed unit he had seen Ian Sherer and Ian Barnwell at the door of the six bed unit having a smoke and a chat. He also thought he had called the ambulance at approximately 10 to 7. He arrived at this time by backward calculation because he waited for the ambulance to arrive and it took some five or six minutes to get there.

He had gone from the six bed unit to the control room to call the ambulance as he believed the phone in the six bed unit only went to the control room and not outside. He had gone to the control room rather than ring from the six bed unit to the control room because he believed there may not have been anyone left in the control room after Mr. Withers had left.

Mr. Bennett indicated that between about 6.30 and 6.33 he heard a conversation between Mr. Baker and Mr.

Sherer. Mr. Bennett indicated that at that time he and Mr. Sherer were having a chat together. He also indicated that generally speaking if you turn up early you are asked to go up and relieve the night shift so that there was an expectation on his view that he or Ian Sherer would have been requested to go and relieve Mr. Barnwell. He then recalls that when he and Mr. Sherer were talking together Danny said to us together "If you want to talk you can talk later, I need Ian up in the six bed unit to relieve Ian Barnwell". (Transcript 16.10.98, page 69) He gained the impression that Mr. Baker was a bit anxious to get Sherer up to replace Barnwell.

Mr. Bennett recalls remaining in the control room preparing for the day's activities and then recalls looking up to see Ian Sherer approaching the six bed unit and saw Ian Sherer and Ian Barnwell having a chat and a smoke. He was not sure whether they had a full smoke or just part of a smoke.

It was his estimation that it was between five and seven minutes between the time he had seen Ian Sherer leave the control room and the time he saw him at the door of the six bed unit. He thought this would have then made the time about 6.35 to 6.40 when he saw them at the six bed unit door. He thought he had kept them under observation at the door for about ten to fifteen seconds and then went about his business. He then returned to the staff room and read the paper and finished his coffee. He was not able to recall how much time elapsed between him leaving the control room and Chris Withers shouting at him. He initially thought there had been an escape and he moved quickly in response to Mr. Withers' shout.

He indicated that when he arrived in the middle of the sally port he had a clear view up the hill. His memory is that Ian Barnwell was half way down the hill and had turned and ran up with Chris Withers. He did not see Danny Baker when he ran down the stairs and did not recall seeing his vehicle in the area.

When he entered the room where Mark Watson was he saw Ian Barnwell and Chris Withers holding Mark Watson's legs and Ian Sherer was on top of the desk. He indicated that Ian Sherer couldn't untie the knot and he jumped up on to the top of the table and undid it. It took about 5 to 20 seconds to get Mark Watson down and laid on the ground. He left the cabin to go and ring for the ambulance. When he returned to the six bed unit he noted that Mr. Withers was not well and Mr. Bennett took over the mouth to mouth resuscitation for a short period.

He recalls the ambulance officers asking questions but was not sure about the details. He recalls Mr. Withers answering questions but cannot recall whether Mr. Barnwell said anything at all.

AMBULANCE SERVICE GORDON MUNRO BOYD Mr. Boyd was an ambulance officer employed by the A.C.T. Ambulance Service and gave evidence concerning times in relation to the call for ambulance assistance and the process involved in dispatching the ambulance. He indicates that the triple 000 call was received by the A.C.T. Ambulance Service at 6.51 and 1 sec. on the 17th of September 1996. The records kept and produced and marked as exhibit 82 indicate that the call was received from 62070600 which is the phone number for Quamby.

It is not necessary to go into any detail into the process involved in the recording of various times other than to indicate that the ambulance was booked as a result of the actions of Mr. Boyd at 6.53. The ambulance was dispatched at 6.55. The ambulance arrived at 6.58 with a complement of two paramedic ambulance officers, Ms.

Kylie Edwards and Mr. Andrew Alexander Edwards. The principal evidence giver in relation to the activities of the paramedic ambulance officers was given by Ms. Edwards.

KYLIE EDWARDS She indicates that from her records the ambulance arrived at Quamby at 6.58 and departed at 7.26 for the hospital and left the hospital at 8.13. She indicates that upon arrival at Quamby she asked various persons present a number of questions in an attempt to obtain a clear history upon which she could base her treatment.

She indicates that there was substantial difficulty in obtaining a clear history and that she thought they obtained three or four different stories within the first two minutes of arriving. Her memory was that there were two people doing CPR and probably three or four others standing around. Shortly after the arrival of herself and Mr. Edwards a second ambulance arrived and two additional paramedics came to the six bed unit.

Upon arrival Ms. Edwards arranged for the removal of Mark Watson from his unit into the larger common area.

She indicates that it was very important for her to obtain as much information as possible and in particular some indication of how long Mark had been hanging so as to formulate the proper treatment. She indicated that she was told that he couldn't have been hanging for more than 15 minutes because he was on 15 minute observations for a suicide watch. She thought two people had said that to her. She thought at one point in time someone had said five minutes but that person seemed then to step into the background. She ultimately thought that most of the information she received was from a person whom she believed to be the person in charge.

Ms. Edwards indicates that there was a lot of confusion and those who were providing the information didn't seem to be able to decide whether it was 6.35 that Mark was found or 6.40 that he was found but she accepted that it was 6.35 that he was found and 6.40 that they actually got into the room to him because this person stepped forward and said this is the time.

She thought that one person had provided information that Mark Watson had been observed to be sleeping at 6.15 and found hanging at 6.35 and that that person was the same person who had indicated that Mark Watson couldn't have been hanging for more than 15 minutes because he was observed at 15 minute intervals. The

impression she gained was that she was being told that there had been a five minute delay in gaining access because of the unavailability of keys. Ms. Edwards that she indicated that she had very strong doubts about what she was being told. She was pressed in an attempt to identify the person or persons who were giving her the information that she was attempting to operate on. She was asked (Transcript 5.11.97, page 18) "Well, I'm not asking you about faces, but did you notice where they came from relative to where you were?---No, I believe it was the guy at the chest, because the guy at the head was really stressed out because he had been doing mouth to mouth unprotected and he was quite stressed about the whole thing, on edge".

The person of course who was at the chest was Mr. Barnwell while Mr. Withers was doing the mouth to mouth unprotected.

Ms. Edwards gave a body of evidence concerning observations made by her relating to the condition of Mark Watson and it was ultimately upon this evidence, at least in part, that Professor Herdson formed his assessment that Mark Watson had suffered circulatory failure at about 6.30 a.m.

It is clear from the evidence of Ms. Edwards and Mr. Edwards that there was a substantial degree of difficulty in obtaining any clear picture from those who were present in the six bed unit. While it would seem that a number of people contributed to the comments being made it would seem more likely than not that the principal responder to questioning was Mr. Barnwell. It is not certain whether Ms. Edwards was confused as to the comment concerning 15 minutes but whatever was occurring it was clear that she was not able to obtain any clear picture as to what had occurred at a time within about half an hour of the actual events. One could accept that there would have been stress and anxiety present, particularly in relation to Mr. Barnwell, but it is difficult to understand why there was the degree of confusion that clearly existed as well as an apparent reluctance on the part of those present to contribute meaningfully to the history being sought by Ms. Edwards. One must have an anxiety that even at that stage there was an emerging reluctance on the part of Mr. Barnwell in particular to clearly indicate his memory of the events of that morning.

It is clear from the evidence in relation to the ambulance officers that the triple 000 call was received at 6.51 and that the ambulance arrived at Quamby at 6.58. There can be no avoiding these particular times.

QUAMBY YOUTH DETENTION CENTRE The institution to which Mark Watson was delivered by the police on the 13th of June 1996 is a centre which had its beginnings in about 1962. It originally commenced operation, in a different set of buildings to that which it occupied in 1996, as a shelter for the purposes of keeping children in a place of safety pending court appearances. The institution commenced to operate out of the buildings which it currently occupies on the 25th of March 1994. In 1988 the institution dramatically changed its role in that it began to accept children who were subject to committal orders as well as children awaiting court appearances. This change caused a dramatic alteration of the basis of the operation of Quamby and created a circumstance in which it appears that since that time there has been continual difficulty experienced by staff and management in handling the diversity of children who are resident at Quamby. This diversity can include children of tender years on remand or serving committal, male and female of various ages and in particular older children, sometimes adults over the age of 18 who are serving committals. One of the concerns which clearly come out of the evidence of almost all of the staff or management at Quamby who gave evidence before me is that this mixture of persons causes ongoing problems for management and has led to conflict not only between staff and residents but also between staff and management.

The management of Quamby came under various departmental responsibility over the years. Mr. Richard Young indicated in his evidence that he had been employed at Quamby since 1988 and that over that period he had reported to some six or seven people.

He also indicated that during his time at Quamby ministerial responsibility had changed on at least five occasions. These changes, he thought, related more to changes of ministerial responsibility rather than any philosophical premise. The changes, however, do reflect in my view an ongoing lack of clarity and certainty as to the precise operational role of Quamby and an inability on the part of those who have been responsible for Quamby particularly since 1988 to come to adequate grips with the dynamics created by the unusual and perhaps undesirable intermingling of different categories of residents.

As at the date of the death of Mark Watson Quamby was under the ministerial supervision of the Department of Education & Training and was part of the Children's, Youth & Family Services Bureau. Mr. Young as at that date reported directly to the Executive Director, Family Services, Ms. Christine Healy. Subsequent to the death of Mark Watson the structure to which Mr. Young was directly responsible changed and his evidence indicates that

in February of 1998 various titles were changed and Mr. Young's title was changed from Director to Principal Manager and he then reported directly to Mr. Michael White, who is the Executive Director of Children, Youth and Family Services, rather than to Ms. Christine Healy.

Mr. Young's role, as I understand it, was that he was the head of one of the arms of Family Services relating to Youth Justice. In that managerial position he had responsibility for the Quamby Youth Detention Centre and also for the Community Unit which dealt with persons not resident at Quamby.

Under Mr. Young there were people who managed and were described as the manager of the residential unit, Quamby, and a person described as the manager of the Community Unit. Both these persons were directly answerable to Mr. Young.

The evidence indicates that for many years there had not been a person permanently appointed to the position of manager at Quamby and that this office had been occupied by a substantial number of persons in an acting capacity. As at the date of the death of Mark Watson this acting manager's job was held by Mr. Franc Woods.

The staffing arrangement at Quamby consists of the manager, persons occupying positions described as shift supervisors, supervisors and youth workers.

The day to day operations of Quamby are built around a shift roster of a traditional type; that is to say an A, B and C roster so described, being split up in the following way. The A shift is the evening shift which commences at 11 p.m. and continues until 7 a.m. On this shift there was traditionally only two workers, namely a senior youth worker acting, in effect, as a shift supervisor and one other worker. This situation changed if there was a resident subject to some form of special observations and in those circumstances a third worker was employed. The B shift operated from 7 a.m. until 3 p.m. and consisted of a shift supervisor, a senior youth worker and a number of other youth workers being approximately seven in number. The C shift operated from 3 p.m. until 11 p.m. and consisted of a shift supervisor, a senior youth worker and a number of youth workers, usually about seven in number.

The general running of the centre was controlled by the manager at times in co-operation with another person described as the psychologist who could, along with the manager, issue manager's directions or instructions which were required reading for the staff. In addition there was a policy and procedure manual and some element of training for the various workers.

During the course of shift operations various documents came into existence all of which bear a significant role in relation to the operations and particularly the historical knowledge of persons operating within the centre. The principal source of documentation is the control room log which was under the direct control of the senior person acting as the shift supervisor and the shift handover sheets which were completed again by the senior person acting as the shift supervisor.

The general operation of the centre allowed for observations to be conducted on all residents every 30 minutes, particularly during the evenings and also during any period when the resident was in his/her individual unit.

During the course of the day's activities residents were, as I understand it, generally observed while going about those activities rather than observed in any particular time frame. In addition to these general observations there were from time to time special observations required relating to individual residents and these could vary from five to fifteen minutes. As a general rule a resident subject to such special observations was observed during periods in which the resident was within their individual unit, particularly during the evening and such observations were required to be recorded in a book described as the special observation book.

Upon arrival at Quamby a person, particularly one on remand, was taken to an area described as the induction area and there interviewed by one of the workers, generally a youth worker. Information was obtained by that youth worker concerning the resident and this information was then used to initiate an individual file which was kept at the centre relating to that individual resident. At that point in time, that is to say upon arrival and induction, an assessment was made by those on duty, more specifically the shift supervisor or senior youth worker who was acting as a shift supervisor, as to the placement of the resident and whether any special observations might be appropriate in relation to that resident. While the evidence on this point is not absolutely clear it does seem that there was a rule of thumb that any person being admitted to Quamby for the first time would be regarded as being at greater risk of self harm or alternatively in greater need of close support and observation than a person who had previously found themselves in a similar custodial situation. If such a rule of thumb applied then the evidence would suggest that it was not applied in the case of Mark Watson. While there is no documentary evidence to indicate where he was placed upon arrival the special observations book to which I refer in the section entitled "First Remand In Quamby" seems to suggest that he was originally placed in the eight bed unit and not placed on any observations at all. A change occurred and observations commenced, it would seem, in accordance with the entries in the special observation book. A decision concerning placement and/or special

observations was made as a general rule by the shift supervisor although it could be made by the manager or by the psychologist. Once such a decision was made concerning placement or special observations the evidence indicates that the special observations could only be changed following discussions involving the senior workers, and/or the manager, and/or the psychologist but could not be changed, it seemed, at the whim of an individual youth worker or supervisor.

There are a number of matters arising out of the evidence given at the inquest generally concerning the operations of the Quamby Youth Detention Centre which I believe it is appropriate to refer to in some detail. I will now turn to consider these items individually.

KEYS The CSA provides under section 19A for an official visitor to be appointed by the Minister. The functions of this official visitor are set out in section 19B and amongst other things entitle the official visitor to make a report to the Minister.

The official visitor was introduced into the CSA by an amendment to the existing CSA numbered 70 of 1991 on the 7th of November 1991. Mr. William Aldcroft was an official visitor appointed under the CSA. Mr. Aldcroft gave evidence that on the 13th of September 1994 he had officially written in his capacity to the then Minister, Mr.

Lamont, indicating as follows: "Another concern I have arising from a recent incident in the remand section is that the night staff whose duty it is to routinely inspect all resident's rooms do not have a key to enter a room in the event of an emergency situation.

A second youth worker has to be called to bring the key from the control room. This delay could result in a tragedy." Mr. Aldcroft went on to suggest a procedure which might be adopted to overcome this absence of a key.

Mr. Lamont responded to Mr. Aldcroft's letter in a letter dated the 20th of October (I assume 1994) as follows: "You stated that there is no automatic access to young people's rooms for night shift staff. In cases of emergencies the night staff are able to have access to the young offenders' rooms by obtaining keys from the control room. The youth worker is accompanied by shift supervisors so as to safeguard the young person and staff from complaints." A review was conducted of security arrangements at Quamby in July 1995 by a Mr. Salzmann and a Mr. Smith, both of whom were from Juvenile Justice in New South Wales. This review, a copy of which is exhibit 85, raised amongst other matters, the issue of the availability or otherwise of keys for the night shift staff. At page 12 of this report they made the following comment: I feel it important to raise the issue of night shift staff not having key access to residents' rooms due to concerns held by the Department." The question of the availability of a key to open a unit is of utmost significance in relation to the death of Mark Watson. On the morning of the 17th of September 1996 neither Mr. Barnwell nor Mr. Sherer had on them a key which would allow them to immediately access the unit in which Mark Watson was placed. The reason for these workers not having a key flowed from the fact that a key for individual units was not given as a matter of course to workers performing the duties that had been performed by Mr. Barnwell during the course of that evening.

Substantial evidence was given by a number of witnesses in relation to the actual policy which existed at Quamby in relation to the availability of a key to the night shift staff conducting observations of residents.

It is clear that there was at the time of the death of Mark Watson no written direction in relation to a policy concerning keys in this situation. The document, exhibit 70, described as the policy and procedures manual, which was in effect as at the date of the death of Mark Watson, makes no mention of any policy concerning keys.

A number of youth workers, including Mr. Barnwell, Mr. Shore, Mr. Withers, Ms. Rowan, Mr. Sherer and Mr.

Bennett were all of the view that the policy was that keys were not available for night shift workers.

Mr. Baker as shift supervisor had not given Mr. Barnwell a key. Mr. Woods as at 17 September 1996 had never seen a manager's instruction in relation to keys and was not aware of any policy in relation to the availability of keys. He had not been given any instructions by Mr. Young concerning any key policy prior to his taking up his appointment as acting manager. These workers all gave evidence, however, a number of statements were tendered from other workers, including Richard Rueben and April Masters-Smith who also indicated that they

believed no keys were available. Ms. Masters-Smith expressed particular surprise at this policy as it was different to her experiences in her former employment in Victoria. Mr. Young was of the view that the policy was that keys would be available at the discretion of the person in charge of the shift, but how the discretion might be exercised was in no way contained in any documents, particularly in the policy and procedures manual.

Some evidence was given by Mr. Young and others as to the reason behind the policy for the non-availability of keys. This is, as I understand it, based upon a concern held by Mr. Young and perhaps others that the availability of keys could lead to difficulties for staff or residents. The position seemed to be that if a staff member did not have access to a key then it would be impossible for a resident to make a complaint about a staff member which would require the staff member to have had a key. That is to say, it would not be possible for a resident to complain that a staff member had entered the unit of a resident when the key was not available to allow that to occur. It also prevented a staff member from entering a unit.

While I can understand that such a concern might exist it seems to me to be a severe deficiency in a system to have the element of uncertainty that clearly existed amongst the witnesses who were called before this inquest as to what the rules were relating to keys, what discretion existed for supervisors and if a discretion did exist how that discretion might be exercised by the relevant supervisor.

On balance I am prepared to accept that the general view of the staff at Quamby was that the policy prevented keys being available and, indeed, Mr. Shore was of the view that as a result of this particular incident the fact that he now allowed a key to be available to persons still remained in breach of the policy as he believed it existed.

This position was not supported by Mr. Young who believed that there had always been a discretion but I am not prepared to accept in the absence of any written support for this position that the position was as described by Mr. Young. In making this comment I am reminded of the comment made by Mr. Barnwell when he first appeared to give evidence in the inquest that there were many things done at Quamby particular by Mr. Young for which no written support would ever be found.

It is tragic to note that Mr. Aldcroft was required to write to the current Minister, Mr. Stefaniak, in September 1996 reiterating the comment made by him in his letter of 1994 to in effect comment upon the fact that his prophecy of 1994, namely that the delay in obtaining a key "could result in a tragedy", had come true.

It is not absolutely clear on the evidence before me that had Mr. Barnwell or Mr. Sherer had a key to access immediately Mark Watson's unit that this may have prevented his death, but it is clear on all of the evidence that any time saved in this particularly situation may well have been critical. It is important to remember that Mr.

Watson was not dead at the time he was taken from the unit, but was pronounced dead some days later at the hospital. I accept that the evidence indicates that his condition when removed was terminal but the simple fact is that the delay occasioned by the absence of a key which required a key to be brought from the control room some little distance away may well have been an extremely critical delay in this incident. I would recommend that the policy in relation to keys is such as to allow any worker to have access forthwith either by having the keys upon the worker's person or by having the key available in some form of accessible container so as to make immediate access possible.

I am aware that insofar as the six bed unit is concerned that electronic doors have now been installed which would mitigate against the need for keys to be available immediately but the same situation does not prevail in any of the other units. I would not have confidence on the basis of the evidence before me that this is an adequate situation as it is clear that some residents must at various times be at risk of incidents involving self harm which must have a capacity to be instantly responded to and in which delay might be critical. There would also be a concern in relation to an emergency situation, for example, fire.

SUPERVISION/MANAGEMENT As I have already indicated the hierarchical structure at Quamby was headed by Mr. Richard Young. Below him as at the date of Mark Watson's death was Mr. Woods. Mr. Woods was the acting manager of Quamby. Also below Mr. Young in a managerial role was Mr. Hertel, the psychologist. Below these two officers were various people who were responsible for the day to day running of the centre and of whom the principal responsible officer was the shift supervisor. Shift supervisors, as I understand the evidence, regarded themselves as being part of management and not workers in the same way as a youth worker who worked on the floor.

The hierarchical structure in reverse seems to be that the youth workers were responsible for the supervision, care and control of all of the residents of the unit. They were generally on the floor, to use the term frequently referred to by witnesses, and related on a close and regular basis with the residents. A shift supervisor generally remained in the control room although there is some evidence that some shift supervisors, particularly during the day, did move around the centre to remain in contact with the residents. All of those workers were responsible, initially, to Mr. Woods. Mr. Hertel had a role in management in that he could in certain circumstances issue

instructions, sometimes even under the hand of the manager, but apart from that role he seems not to have had any particular role in relation to the actual management of the centre but clearly had a particular role in relation to the care of the residents in the centre. This role was varied but in relation to persons such as Mark Watson he seems only to have had a role in relation to advising others as to what might be the appropriate regime to be applied to any resident. He also had a role in relation to case management but in the case of Mark Watson that role had not developed during his stay at Quamby.

At the time of the death of Mark Watson Mr. Young sat in the position of Director of the whole of the unit of which Quamby was a part and as such was the responsible officer within that area. There are, of course, other officers above Mr. Young who are responsible in an administrative way for the proper operation of Quamby, including at the time of Mark Watson's death, Ms. Healy and Ms. Hinton. For the purposes of this inquest it is not appropriate to make any comment concerning any role Ms. Healy or Ms. Hinton may have had in relation to the operations in an administrative way of Quamby.

The clear responsibility of a managerial type in relation to the events leading to the death of Mark Watson fall upon the shift supervisors, Mr. Woods and Mr. Young. It is appropriate in the circumstances to look at these individuals at this time.

The Shift Supervisor (Senior Youth Worker Daniel Mark Baker) Mr. Baker was the person in the managerial role as the senior youth worker responsible for the conduct of Mr.

Barnwell and Ms. Dillon on the A shift commencing on the 16th of September 1996. I have made some comments concerning Mr. Baker previously. Mr. Baker had the initial responsibility to ensure that Mark Watson and all of the other residents at Quamby on that evening and morning were cared for properly and in safety. It is clear on the evidence that he failed in this responsiblity. He did not, in my view, in any way supervise Mr.

Barnwell or Ms. Dillon during the course of the evening. He recorded entries in the control room log that on the face of it are false. It was his action in ringing Mr. Barnwell prior to 7.00 a.m. which led to Mr. Barnwell's departure from his direct role in conducting the special observations of Mark Watson. It was the failure of these observations that led directly to the death of Mark Watson. Mr. Baker in my view attempted to minimize his neglect and gave evidence which was, if not deliberately false, then certainly grossly mistaken. He must bear the initial responsibility at a management level for the direct circumstances which led to the death of Mark Watson.

Francis Parata Woods Mr. Woods was the acting manager at the date of the death of Mark Watson and had been in this position only since the 12th of August 1996. Once again I have already commented on Mr. Woods role in relation to Quamby, but feel it is appropriate to say under this particular heading that Mr. Woods indicated in his evidence, and there is nothing to dispute this in any other evidence, that he was ignorant of a number of the procedures which he clearly ought to have been made aware of prior to taking over his responsiblities as the manager. He had no real background in institutions like Quamby, his previous history was more in the area of community work. It would seem that his particular interest, which he expressed in his evidence, was in relation to staffing and training rather than the correctional/security aspect of Quamby.

Significantly Mr. Woods in his statement to the police made on the 25th of September 1996, and which is now exhibit 13, indicates that he was present at the centre at the time Mark Watson returned on the 13th of September. He was aware of some of Mark's earlier behaviours and issues, including drug abuse and mental health. He gave a direction that Mark Watson be placed in the special needs unit rather than the remand unit as is standard operating procedure. This direction, it seems on the evidence, was an oral direction and certainly no document has been produced which contains that direction.

The handover sheets for the 13th of September B shift indicate that Mr. Hess was the shift supervisor at that time. There is no notation in the handover sheet which would have been completed by Mr. Hess for the handover to the C shift for the 13th of September making any comment concerning the status of Mark Watson.

Further in his statement, exhibit 13, and in his evidence Mr. Woods indicates that he attended at the centre on the morning of Saturday the 14th of September and observed Mark Watson in the special needs unit. He indicates in his statement that he had concerns at that time and spoke with Peter Dugan, the worker assigned to that unit, and to Cedric Hess the shift supervisor. In his evidence (Transcript 3.11.98, page 53) he indicated he spoke with Mr.

Hess and instructed him to put Mark Watson onto 15 minute observations. He was not sure at that time whether Mark was on observations but he specifically directed that they start.

I note that in the shift handover sheets for the 14th of September B shift Mr. Hess was on duty but there is nothing on the shift handover note for the next shift to indicate that Mr. Hess passed on to the next shift those instructions from the manager. One would assume, therefore, that if Mr. Woods had given such an instruction to Mr. Hess then the only way that the next shift supervisor on C shift, Mr. Mewburn, would have known about it was if Mr. Hess had orally passed it on or placed it on the white board. The control room log book for that shift indicates that Mr. Hess was on duty, and that at 10.20 Mr. Woods was in the centre, at 11.25 he left the centre with a detainee, at 2.10 he was in the centre with that detainee. There is nothing in any of the notes made by Mr.

Hess at that time to indicate that any instruction had been received from Mr. Woods to put Mr. Watson on 15 minute observations. I note that Mr. Woods has signed the control room duty log for the 14th of September for the shift that Mr. Hess was on. I also note that there is no entry during that shift which ends at 3.00 p.m., that Mr.

Woods left the centre after his return at 2.10 and there is nothing recorded in the next shift on which Mr. Mewburn was the shift supervisor commencing at 3.00 p.m. to indicate anything about Mr. Woods.

Mr. Woods was shown exhibit 16, the special observation book, and indicated that his understanding is that Mr.

Watson would not have been on 15 minute observations until at least 2.30 on the Saturday afternoon when he, Mr. Woods, left the centre suggesting that he gave his instruction to the shift supervisor at the time of his departure. It was pointed out to him that the special observations which were recorded in the book concerning Mark began at 10 o'clock on an unnominated date. These observations were half hourly. He regarded that as being unusual that those observations were recorded and he indicated that they should have been 15 minute observations from that time on the 14th. when he gave his instruction. It is also noted that there were no observations at all between 10 o'clock and 4 o'clock.

Mr. Woods accepted that his instruction to Mr. Hess of the 14th of September, the Saturday morning, was oral and that it was unusual for him to be there on a Saturday. He indicated that he would have expected his instruction to have appeared in the handover sheets rather than the control room log. No instruction, of course, appears. I also note that the shift handover sheet for B shift of 13 September 1996 has been signed by Mr.

Woods. There is no evidence as to when he signed it but it is clear that there is no entry on the handover sheet for the C shift to indicate Mr. Woods' instruction re the placement of Mark Watson. This was the last shift handover sheet signed by Mr. Woods at least until C shift of 17 September 1996.

The effect of the evidence is that whatever instructions were given by Mr. Woods to either Mr. Hess or Mr. Dugan they were not carried out. It is clear from the evidence of April Masters-Smith that until she took her action on the evening of the 13th of September that Mark Watson was in the 8 bed unit and not the six bed unit as Mr. Woods indicates he had instructed to occur. It is further clear that any instructions given by him on Saturday morning concerning 15 minute observations were also not carried out. It is not possible in the circumstances to make a definitive finding as to whether Mr. Woods did give these instructions but if he did then for some reason those to whom he gave the instructions chose totally to ignore them. This situation perhaps reflects more upon the practice and procedures that existed at the time than upon the reality of whether the directions were given or not.

Mr. Woods in his evidence indicated that he was approached by Mr. Young on either the Thursday or the Friday concerning taking up the appointment as acting manager. He accepted this offer and commenced his employment on the Monday. He had previously had a two week stint in February as the acting manager. This was his only real exposure to the role of manager of Quamby. He indicates that he had some discussions with Mr. Young in general terms as to his role at Quamby. He indicated (Transcript 3.11.98, page 40) that his role was as follows: "I was only ever put there as a transitional manager to manage the service while they recruited a person for that position and my focus, for the time I was there, was to be on training and development of staff." He did accept, however, that he had a responsibility for running the centre and trying to improve the morale in addition to filling the vacant positions for recruitment and then training and developing those recruits.

He indicated further that in the beginning of his appointment he had daily briefings with Mr. Young and that thereafter there were weekly meetings of the staff and that Mr. Young always attended these meetings but unfortunately by reason of other pressures Mr. Woods was not able to always attend.

It appears from his evidence that upon his arrival to take over as acting manager on the 12th of August 1996 he was substantially deficient in his understanding of the role that he would be required to play. This lack of understanding led to a considerable number of failures or omissions on the part of Mr. Woods at or around the critical dates in September 1996. Some of these failures or omissions are as follows:  Failure to carry out or to instruct any officer at Quamby to carry out any inspection of the unit occupied by Mark Watson following the attempted hanging on the 15th of September 1996.

 Failure to give written instructions as required by the policy and procedure manual, 6.7.3, at the time of directing, on his evidence, that Mark Watson be placed in the special needs unit.

 Failing to ensure that there were written instructions contained in the handover sheets indicating his direction to place Mark Watson on 15 minute observations on the 14th of September 1996.

 A failure to conduct any proper inquiry into the circumstances of the attempted hanging on the 15th of September 1996 and the clear attitude that he took at this time that it was the responsibility of others to conduct any such inquiry.

 Failure to ensure a more appropriate system of delivery of incident reports beyond them being pushed under his door.

 Failure to ensure that a report was provided to him in relation to the result of the attempt to have Mark Watson placed in hospital on the 16th of September 1996 and a failure to make any inquiries as to the result of the attempt to have Mark Watson placed in hospital on that date.

 A failure to understand in any meaningful way his role in relation to viewing and signing the control room log book. It is clear that Mr. Woods regularly signed the control room log book. He signed the book for a number of days prior to him actually taking over as the acting manager on the 12th of August. It is clear that on the pages signed by him there were matters which one would have thought ought to have caused him to conduct inquiries. For example, on the 22nd of August 1996 there is no shift handover at 3.00 p.m. This page has been signed without any inquiry apparently being conducted by Mr. Woods as to why that had occurred.

 Failure to make any inquiry of the Mental Health Crisis Team or of the duty manager in any detail as to the events of the 15th of September 1996.

 A failure to ensure that there was a system, other than that adopted by him, to ensure that staff who were the subject of commendation by him, for example Ms. Rowan and Mr. Shore, became aware of the fact that a commendation in writing did exist.

 A failure by him to in any way become involved in the perusal of the detainees dossier which might have indicated the lack of relevant material contained in that dossier.

 A failure to be aware that persons on special observations were not always automatically placed in the six bed unit.

 A failure to ensure that the shift supervisors were checking the special observation book.

 A failure to be aware of the recommendation of the Deaths in Custody Royal Commission of the need for great care to be taken by management so as to ensure that special observations were properly conducted.

 A failure to do anything to ensure that the observations were being done.

 A failure to be aware as at the date of the death of Mark Watson of any policy relating to the availability of keys to workers in the six bed unit at night.

 A failure to be aware of the early on early off system notwithstanding that there was contained within the control room log clear indications of staff coming in early and occasional indications of staff leaving early.

In my view a review of the evidence given by Mr. Woods and others relating to Mr. Woods' role indicates clearly that his princiapl failure was that he had been put into a job with inadequate training and understanding as to the actual role that he would be required to fulfill during his period in that office. As a result of this lack of understanding and training he was required, particularly up until the date of Mark Watson's death, to rely almost entirely upon the shift supervisors and to a large extent upon Mr. Young. In addition the system of on call duty managers which required the duty manager to report not to the manager but to Mr. Young allowed Mr. Woods to fall, in my view, into a state of false security in relation to his responsibities for the events of the 15th of September 1996. It is clear from his evidence that he had a clear view that the matter had been taken over by Ms. Hillhorst and Mr. Young and that he had no role to play thereafter in relation to the circumstances surrounding Mark Watson. An example of this reliance is that he indicates that he relied totally upon Mr.

Mewburn's report in relation to the search of the room as indicitive that there was no problem existing in that room. It is clear that anyone in Mr. Woods' situation ought to have ensured that there was a thorough inspection of the room following the events of the 15th of September in order to ascertain how something which he himself did not believe could occur had occurred.

I am of the view, however, notwithstanding the above list of failures or omissions on the part of Mr. Woods that his situation is different insofar as responsibility is concerned from other members of the management team. This is because he was placed into the particular role with a mission that did not necessarily require him to be actively involved in the running of Quamby but he was sent there more to attempt to solve the industrial problems that had overwhelmed Ms. Dabin. This as he indicated in his evidence was his principal focus. As a result of this situation he was required to rely to an inappropriate degree upon Mr. Young and the shift supervisors. In this reliance he was at fault as it was ultimately his responsibility to carry out properly and appropriately all of his responsibilites as the acting manager. However, the circumstances in which he found himself mitigate against him being completely responsible for his failures as exposed by the inquest.

It is clear on the evidence that the corruption of the system which led to the failure of the observations pre-dated the arrival of Mr. Woods as the acting manager. Mr. Woods, in my view, attempted within the severe limitations that had been imposed upon him by the system and by the manner of his taking over his appointment as acting manager to carry out what he understood to be his responsiblities with a degree of diligence.

Regrettably, however, his impact upon the institution and the systemic problems at Quamby are best evidenced by the complete failure of the shift supervisors of the 13th and 14th of September to pay the slightest attention to the directions that Mr. Woods gave to them, on his evidence, relating to the placement and supervision of Mark Watson.

Richard Young Mr. Young was at the date of Mark Watson's death the Director of Youth Justice and as such had the direct responsibility over the manager for the management of Quamby. Mr. Young had a long and extensive career, particularly in corrections. He had been appointed to Quamby in 1988 when the facility changed from being a shelter complex to a youth justice complex. Mr. Young remained in that same position although the title of his office apparently changed from time to time until at least October 1998, the date of his giving evidence.

The submissions filed on behalf of the Australian Capital Territory Department of Education and Community Services says at page 41 "Richard Young's position as Director of Youth Justice has been abolished. Quamby has commenced the necessary processes required by the Public Sector Management Act 1994 to terminate the employment of Mr. Young. This is expected to be completed by March 1999." Subsequently a letter dated the 4th of March 1999 was received from Mr. Bayliss, the Solicitor instructing Mr. Erskine, who appeared on behalf of the Territory and the Department, referring to the submissions and indicating "In order to avoid any ambiguity it should be understood that the position of the Director of Youth Justice will continue to exist into the future. It is the staff position held by Richard Young that has been abolished. Further the processes required to separate Richard Young from the Public Service are a complex interaction between Industrial Awards, which have the effect of Commonwealth legislation, and the provisions of the Public Sector Management Act. Those processes have been commenced. The specific processes required by the Public Sector Management Act, which in terms of the sequence comes towards the end of the separation process, will commence during March." For reasons which I will enumerate below I would support and commend this decision, however, I do have some reservations about the continuation of the role of the Director of Youth Justice in its involvement with Quamby unless there is a clear indication within the documentation relating to the two roles that the manager has full and final responsibility for the management of Quamby and merely reports in an administrative way to the Director of Youth Justice. If a person is appointed to the office of Director of Youth Justice who conducts his responsibilities in the way Mr.

Young has then it would seem to once again open the door for confusion and misunderstanding. Great care must be taken, in my view, in relation to the delineation of responsibilities between the manager of Quamby and the Director of Youth Justice.

Mr. Young represented, on the evidence before me, the only continuity in management at Quamby. He also represented the only real experience in a custodial setting. No doubt there were others employed, including Ms.

Dabin, who did have a custodial element in their experience, but it is clear from the evidence that Mr. Young represented of those persons who came before this coronial inquiry the most substantial repository of knowledge and experience.

All of the evidence points to Mr. Young being "a hands on manager". It was suggested to Mr. Woods that he was a puppet of Mr. Young. He denied this but it is my impression of the evidence that while Mr. Young may not have been strictly speaking a puppet master it is clear that all of the strings relating to the running of Quamby were in his hands. It may be that some of them passed through other parties' hands but all of them ultimately were in his.

For example, Mr. Woods reported directly to Mr. Young. As I have indicated above in relation to Mr. Woods he was at September 1996 a very inexperienced person in relation to the running of Quamby. He relied to a very large extent upon his contacts with Mr. Young to enable him to carry out his responsibilities at Quamby. For a period following his appointment in August 1996 he had daily contact with Mr. Young.

The psychologist also reported to Mr. Young, either directly in certain difficult cases, or indirectly through the manager.

Most tragically the on call duty manager reported directly to Mr. Young. I note in the 1995 Review of Security Arrangements of the Quamby Juvenile Justice Centre, Canberra, A.C.T., exhibit 85, that the persons carrying out that review made the following comment: "The current system of on-call duty being share with community based managers should cease an the manager Quamby should be on call, other than or roster days off duty and should be paid at on-call allowance."(sic)

There are, in my view, based upon the evidence two tragic flaws in the reality of the operation of Quamby which led to the death of Mark Watson. The first is the failure of the system overseen by Mr. Young to ensure that the observations required to be carried out by Mr. Barnwell were carried out and, secondly, the complete breakdown of the system relating to on call managers. This is not a criticism of Ms. Hillhorst who in my view performed her role appropriately but it is a criticism of Mr. Young and the sytem generally. The requirement that the on call manager, in this case Ms. Hillhorst, report direct to Mr. Young rather than to Mr. Woods, allowed a situation to develop in which all of those, namely Mr. Woods and Mr. Young, who had direct responsibility for the safety of residents at Quamby, were able to evade that responsibility by assuming that each other may be doing the job.

Mr. Woods' view as expressed clearly in his evidence was that he accepted that the incident of the 15th of September, which directly led to the hanging on the 17th of September, had been taken over by Ms. Hillhorst and Mr. Young and that there was nothing further required of him. Such was his confidence in this arrangement that he left the centre and did not return that day. Such was the confidence of the staff in that arrangement that they did not even bother to contact Mr. Woods to advise him that Mr. Watson had returned to Quamby that day. His first knowledge of the return of Mr. Watson to the centre was when he was advised on the morning of the 17th of September that Mark Watson had again hung himself. It is not clear on the evidence before me as to how the system of reporting relating to the on call duty manager evolved, but it would seem inevitable that it was a matter that Mr. Young was responsible for. He was the only continuity in the management for a substantial number of years. The system of reporting by way of on call manager was so ludicrous that Mr. Woods, himself while the actual manager, had to report to Mr. Young concerning any activities that he may have been engaged in while the on call duty manager.

The recommendation made in the 1995 report clearly indicated that those experts who investigated the matter were dissatisfied with the system and called for its immediate cessation. Regrettably this recommendation, as well as other recommendations made in that report, were not acted upon by either Mr. Young or anyone else in a responsible position to ensure that such recommendations were dealt with and acted upon where appropriate.

The tragedy of the 1995 report, which was to a large extent ignored by those responsible for the management of Quamby, is that two of the serious problems which were exposed in this inquest were exposed in that report, namely, the problem of the on call duty manager and the problem of keys being available to night staff. If this report had been acted upon at the time then two of the substantial risk factors which led to the death of Mark Watson may well have not existed as at September 1996.

Mr. Young indicated that there had been a substantial degree of instability in the management of Quamby over a period of years. His evidence indicates that it was at least three years prior to October 1998 since there had been a permanent manager. This time scale may be incorrect as evidence of others indicate that there had not been a manager in a permanent position at Quamby since Mr. Van Hinthum some considerable years before. Mr. Young indicated that there had been at least eight longish term temporary managers and perhaps as many as a further five, including Mr. Barnwell, acting as manager from time to time. He also indicated that there had been four attempts to fill the job unsuccessfully. It is not clear and there is no real evidence before me as to why this failure to fill the job occurred but it would seem to be at least in part related to the positioning within the public service of the particular job. Ultimately at the time of the inquest, October 1998, the evidence was that the position had now been upgraded to an SOG B which was the same level as the position held by Mr. Young.

Mr. Young indicated that he did not believe that the failure, for whatever reason, to obain a permanent manager caused a lot of operational issues to fall to him. However, one must accept that while that was his view the evidence would tend to suggest that the reality was perhaps somewhat different. This situation is, I believe, exemplified by the fact that the ongoing industrial disputation led to a meeting of staff at which a motion of no confidence was passed in Mr. Young. It seems surprising that Mr. Young, who in my view took great pains to distance himself from direct responsibility for the management of Quamby, was regarded by the staff as a person of such close connection to Quamby as to be worthy of having a vote of no confidence passed in him. I am content on the evidence before me to accept that Mr. Young had a very active and involved role in relation to the management of Quamby and that he clearly failed in carrying out that responsibility.

Additionally the 1995 review raised concern about the role of Mr. Young in Quamby. The report states as follows: "The present location of the Director in the centre causes confusion for staff and does not allow manager to operate totally. Director's office should be located to another area out of Quamby." This comment seems to me to reflect a view of the confusion caused by the presence of the office of Director and also by the fact that the office of the Director was occupied by someone of the background of Mr. Young. It seems to me to be inevitable that there must be an element of defacto control of Quamby by someone such as Mr. Young holding that particular office. By that I mean that Mr. Young was an experienced corrections officer who had been at Quamby for many years and it was inevitable that those below him would be inclined to take more notice of anything that he said as opposed to what the manager said. Mr. Young clearly had an active role in relation to the running of Quamby. While he was not within the physical confines of the Quamby institution every day, he was there at least once a week and his presence was only removed by a short distance. It is my

view that it is not appropriate that there be an office of a director to whom the manager is responsible in the way that a manager has been responsible to the director in the past. As suggested in the 1995 review the office of the director and its occupation by Mr. Young "does not allow manager to operate totally". I am of the view that this matter highlighted by that report has been clearly displayed in the circumstances of the activities of Mr. Woods.

His capacity to operate properly as the manager was restricted by Mr. Young's inadequate training of him prior to taking up his role, Mr. Young's overshadowing presence at Quamby and, more importantly, by the failure to require the on call duty manager to report to Mr. Woods. If Ms. Hillhorst had discussed the matter with Mr. Woods then one would hope that Mr. Woods would then have acted in a different way to the way that he was able to act on the 16th of September.

Mr. Young indicated in his evidence that it was not his perception that his physical presence created confusion as had been suggested in the 1995 review. He was aware of the contents of that review but was unable to understand how those that did the review came to that conclusion.

Mr. Young indicated that he always did his best, no doubt with the assistance of the acting manager, to ensure that the manuals were up-to-date and properly prepared. This refers to the manual containing the Quamby Youth Detention Centre Policy and Procedures Manual. Exhibit 70 represents the document which was in existence as at the date of Mark Watson's death. He accepted over the course of his evidence that this manual did not contain a number of critical matters which it ought to have contained. Some of these are as follows:  There was no indication in the manual as to the position relating to staff members, particularly on duty during the night, having keys to units. Mr. Young had indicated in his evidence, which was contrary to nearly all the other evidence, that there was a discretion available to supervisors to hand out keys. He accepted that there was no such discretion indicated anywhere in the manual.

 There was nothing about how restraint might be used in relation to residents.

 There was nothing about how to conduct observations.

 There was nothing concerning prevention of suicide.

It was suggested by Ms. McGregor that the manual contained nothing that might lead to the proper care and safety of a resident. There is substantial merit in this suggestion.

Mr. Young indicated that the purpose of the policy and procedures manual was "to provide a framework for staff's interreaction and operation within the centre and with the clients" (Transcript 22.10.98, page 72) Having made this statement he was then asked to look through the manual in relation to observations and how people would carry them out. He conceded he could not find such an entry but "accepted that it would be a very important thing to contain in such a document". He was not aware why it was not in the document but he accepted that the manual would have been cleared through him before it was circulated. He accepted that people seemed to be less than aware of the existence of the manual but would not accept that the use of the document would be zero but it was not as high as he would like. He was ultimately responsible to ensure that the staff for whom he has responsibility were aware of the manual and in particular that the manual was created in such a way as to enable those who were required to use it to be able to use it in such a way as to be able to do their job properly and be aware what their responsiblities were.

I have already commented in relation to Mr. Young's role in the events of the morning of the 16th of September

1996. It is not necessary for me to reiterate those comments but it is clear that Mr. Young failed to take any action to ensure that any inspection was made of the unit in which Mark Watson had attempted to hang himself on the 15th of September. It is also clear that he failed to take any action to ensure that Mr. Woods was adequately aware of what was going on and it seems that Mr. Woods was not invited to the meeting. This division of responsibilities led to the failure on the part of management at any level to adequately cope with the events of the evening of the 15th of September which contributed in a large part to the tragedy of the morning of the 17th of September.

Mr. Young also accepted that there was nothing in the manual to advise staff what they were to do with all of the bits of paper that might be generated during the course of any individual detainee's stay. He accepted at the same time that it was important that information be maintained for continuity and accepted that there didn't seem to be a working system at that time in Quamby that achieved this purpose.

Mr. Young gave some evidence concerning the JIM computer system. He was surprised to find that his evidence of the 20th of October 1998 was the first time that this system had been mentioned. It may be true, as Mr.

Erskine indicated, that no one had asked a question about the JIM system but the fact is that a number of witnesses had gone through the inquest who had a responsibility to record information concerning residents and none of these had mentioned a capacity to use a computer data base.

The evidence is clear that there is a substanial overload in relation to pieces of paper which are created at Quamby. The control room log, the handover sheets, incident reports and manager's reports are amongst those that are very significant in the day to day running of Quamby. It is clear from the evidence that many of these documents are inaccurate or inadequate. It may be that serious consideration needs to be given to the compulsory use of an appropriate data base so that all of the information relevant to an individual detainee or resident can be kept in the one place. This would involve a greater access for all staff members to computer equipment and additional expense in training. However, it would appear on balance that these expenditures would ultimately achieve a more useful purpose than the ongoing system continuing. There is nothing in the procedures manual to suggest any requirement for the use of the JIM system. Perhaps this ought change.

Mr. Young indicated in relation to the meeting of the 16th of September 1996 that he lacked detailed knowledge of the circumstances of the attempted hanging and that he had not conducted any investigation or inspection of the room. He was asked the following question: (Transcript 23.10.98, page 50) "Where do you see that you failed in that particular context?---My failure in that particular context was that the decision making that was being done by my staff wasn't up to scratch. I should have been aware of that, I wasn't." A number of other issues were raised during the course of the evidence which would seem to directly involve Mr.

Young. The first of these is the availability of keys and I have already specificially commented upon this and will not reiterate my comments. It is clear, however, that the policy concerning the keys seems to have emanated from Mr. Young and it is also clear that there was no precise policy formulated as to be clearly known to all of the staff members at Quamby. Whether the keys were available or unavailable is only part of the issue. The real issue was that it was a responsibility of management to ensure that all workers clearly understood the policy and that there was no ambiguity in relation to their knowledge.

A second issue related to the availability of oxyviver equipment. There was some evidence to suggest that there was no such equipment available, but Mr. Young's position was that there was such equipment available but for whatever reason it was clearly not used on the morning of the 17th of September 1996. Again, the issue may not be significant other than to represent another example of ignorance on the part of workers as to the availability of such equipment. The evidence before me clearly lacked certainty as to the state of knowledge of workers. It is clear, however, that whether the equipment was available or not it was not used. One would have thought that there ought also to have been a clear direction contained in the policy and procedure manual to indicate the availability of such equipment, where it was kept and clear training provided to all relevant persons on its appropriate use. Once again it is clear that many if not all of the workers had some element of first aid training. It is suggested that first aid qualifications are a requirement of employment at Quamby. It is certainly not clear that all had specific training related to whatever equipment may or may not have been available as at September 1996.

A further matter of some contention was the unavailability of a Hoffman knife. This I have briefly referred to but there is some evidence to suggest that Mr. Young may have actively resisted the introduction of such a piece of equipment. This evidence was not pursued in any detail and it is therefore not appropriate for me to make any finding as to what role Mr. Young may have had in relation to the unavailability of a Hoffman knife. It is clear on the evidence that the death of Mark Watson occurred some months after the death of Shannon Camden at the Belconnen Remand Centre and that any information which Mr. Young concedes he obtained concerning the incident at the Belconnen Remand Centre ought to have indicated to him the essential presence of a Hoffman knife. Notwithstanding this information no knife was available in September, 1996. It may be inappropriate to sheet home the responsibility for the absence of a Hoffman knife to Mr. Young, but it again reflects deficiencies that could have easily been rectified if anyone had put their mind to them. There was a specific incident, that is to say the Belconnen Remand Centre incident, which one would have thought would have allowed a direction of minds by those responsible for the safety of residents at Quamby to lead to the obtaining of a Hoffman knife.

He indicated that his last involvement on the morning of the 16th of September was to be aware following the discussion with Ms. Hillhorst that Mark Watson was to go to court. Later he ascertained that he had appeared in court, been to the hospital and returned to Quamby.

He seems to indicate that he was not aware of the poor nature of the completion of the observation book and upon inspection of the observation book accepted that there was no sign that any of the books had ever been signed by a supervisor which was in breach of the requirements of the instructions.

He was not aware of the fact that one staff member was required to do five minute observations all night but would have expected that there would have been a rotation during that period.

He indicated that he was aware of the recommendations made in the Deaths in Custody Royal Commission concerning the need to keep a careful check in relation to the proper conduct of observations. He further suggested that he did do this by checking with the managers who assured him that they checked the special observation books. He was then shown the books and accepted there was no sign of the managers ever having signed them and it was suggested to him that the managers may have lied to him about this particular situation.

He accepted that that may well have occurred.

He was not aware of the early on early off regime. He was asked: (Transcript 23.10.98, page 75) "We haven't been able to find, I don't think, a shift that actually was in accordance with what the requirements of the Public Sector Management Act and the requirements of Quamby were?---That's very disappointing, that." He indicated that he was not aware of that fact.

At he was asked (Transcript 23.10.98, page 78): "It seems to be with respect, Mr. Young, based upon what we have heard and what you've conceded now to be an extraordinary large number of things that you'd never heard of as to how your centre was running?---It does appear that way, yes.

Why would that be?---I couldn't answer that.

Well ultimately you were the one who was supposed to be responsible for the proper running of it weren't you?-- Yes.

And yet whatever you thought was happening clearly has no relationship to the reality of what was occurring there?---That appears to be the case from time to time.

Well it seems to be the case almost all the time from what I've heard. Do you agree or disagree with that?---No, I would disagree with that." With the greatest of respect to Mr. Young I am not able to accept his disagreement. It would appear from the evidence that he, as he accepts, had the ultimate responsibility for the proper care and safety of the residents at Quamby. While I accept it is not his responsibility to be aware of every single thing that might occur in the institution it is his responsbility to ensure that systems are in place that ensure that the people resident at Quamby remain safe. It would also be, in my view, his responsibility to ensure that those systems were sufficiently well supervised to ensure that they were properly carried out. This did not occur. Two comments were made during evidence by Mr. Woods and Mr. Barnwell which I believe ought conclude this particular section of the review of the evidence. Mr. Woods was asked: (Transcript 2.11.97, page 105) "What is the usual practice for the on call manager as far as briefing the manager for the next day?---When you are talking about the manager, you are talking about Richard Young or are you talking about me?

Mr. Barnwell in his first appearance made the following comment: (Transcript 12.11.97, page 28) "Mr. Young is a very cunning man. You'll hardly ever track him down with documentation because word of mouth is easier to get out of than having documentation there. As with the keys issued it was a directive from Mr. Young that no staff member will carry keys to the units on night shift, to the accommodation units on the night shift. You won't find any of that written down in the polic (sic) and procedure manual. You won't find it written down in any written form of communication. However it is well known by all staff out there that you do not carry keys on night shift because the director has said that".

While one might have reservations about much of what Mr. Barnwell said in my view his assessment of Mr. Young based upon the evidence given by the witnesses, including Mr. Young himself, support the opinion of Mr.

Barnwell. Mr. Young was a very unimpressive, evasive, equivocating and quibbling witness. He had to be directed on a number of occasions to answer the question put to him. He frequently answered in a different way to that which one would have expected from a person who was attempting to assist the inquest. He was not prepared in many circumstances to accept the reality of his responsibilities but attempted to distance himself from those responsiblities. I am not able to indicate other than that I was unimpressed with the evidence given by Mr.

Young. He carried a great and weighty responsibility in relation to the safe care and custody of Mark Watson.

While it is not fair to say that it his responsibility alone that Mark Watson died he must carry a very substantial degree of that responsibility. He among all the persons involved in an administrative management role at

Quamby had the capacity to ensure that the system in place to prevent Mark Watson hanging himself adequately worked. As a result of the corrupting of this sytem over a long period of time the system when put to the test failed. Not only did it fail because Mr. Barnwell did not do his observations but it failed because Mr. Young did not act properly when the on call duty manager reported to him. These and the other failures outlined above led regrettably to the death of Mark Watson.

STAFF PROBLEMS It is clear from the evidence that there had been at Quamby over a long period of time substantial difficulties between the staff and management. By reason of the rulings that I made prior to the recommencement of the inquest in October 1998 it is not appropriate for me to embark upon any detailed study of the various matters raised during the earlier portion of the inquest. As I have already indicated I intend to refer much of the material made available to the inquest to the Attorney-General for consideration by the Attorney-General as to what, if any, future action might need to be taken in relation to that evidence.

I feel, however, notwithstanding the restrictions imposed upon the conduct of the coronial inquiry that it is appropriate to make a number of general comments based upon the evidence before me.

It appears clear from the evidence of all those involved from Mr. Young down that the dynamics of the mix of children and sometimes adults contained within the Quamby centre present unique difficulties for those who work in that centre. General comments made about institutions in other places and particular comments made by Ms.

Batzias in her affidavit, exhibit 274, would tend to indicate that in most other jurisdictions there is a variety of institutions available to deal with different categories of children. Because of the size of the Australian Capital Territory it may not be economically feasible to have a wide range of institutions available within the Territory.

This economic difficulty has led to the creation in Quamby of a multi purpose institution which must cater for residents of various ages, both male and female and with quite substantially different problems and requirements.

The problems of this situation are exemplified by the presence in the six bed unit on the 16th of September 1996 of a number of persons all of whom in other jurisdictions may have been kept in separate institutions. There was a female present and a number of young men, some of whom, if not all of whom, were serving committals and were not on remand. The presence of persons serving committals create an entirely different problem for management as it is important that there be in place substantial case management programs to ensure that the rehabilitation of these children proceeds appropriately. It is clearly a day to day difficulty for all involved in the conduct of Quamby to have this cross-section of persons present in the institution and it would seem clear from the evidence that this mix has led to at least part of the volatility involving the staff disputes between the workers and management.

It would also appear that there is a philosophical issue raised between those of the staff who take the view that people are in the institution for punishment or correction as opposed to those who perhaps more appropriately take the view that committed persons, at least, are present in the institution in order to be rehabilitated so that they might in due course return to the community and be better able to live a normal law abiding life. There was some suggestion made by a number of the witnesses that this particular philosophical difference was also a signficant irritant in relation to staff management relations.

It is not my role to form a view as to how institutions in the Territory might be run particularly as I have no material concerning the economic consequences of any observations I might make, nor do I have any real evidence from appropriate witnesses in relation to the type or number of institutions which might be necessary and/or appropriate for the Territory. However, it does appear clear that there is a need at this present time for servious consideration to be given to the ongoing future role that Quamby might play in the corrections activities in the Territory. This is particularly significant at this time as it is a well known fact that the government is considering the construction of a prison in the Territory. It would be my view that it would be appropriate for the government to consider during the discussions concerning the provision of a gaol for the Territory as to whether it might be appropriate that there be a separate facility nearby the prison to which older children and adults might be committed to serve committal orders. I have no evidence as to the actual numbers which may be involved in such a facility but it does appear clear that the presence in Quamby at the present time of young people who have had considerable experience of institutions coming into daily contact with young people such as Mark Watson who have no experience of institutions can lead to complications in relation to the intermixing of those persons. These complications can lead to difficulties for individuals as has been suggested in the case of Mark Watson as well as difficulties in relation to the management of the centre.

I do not wish it to be thought that I am suggesting that children committed to an institution in the Territory ought at any point in time be placed in an adult facility but it is clear that there may be benefits to be obtained by having a juvenile justice facility adjacent to the adult facility but operated separately. It is clear from the views expressed by Mr. Young and others that it is not desirable to have an intermixing of adults and juveniles but it is clear that some juveniles do need to be kept separate from other juveniles who might be more appropriately dealt with in

Quamby. The same situation may apply in relation to female detainees at Quamby but the numbers in relation to this are not known to me and it may be genuinely inappropriate for female detainess to be separately dealt with within the A.C.T. It is clear from the evidence that the presence of female detainees creates particular problems for management at Quamby.

I note that since the death of Mark Watson substantial changes have occurred in relation to the staffing. I note that many of those who have given evidence are no longer employed at the institution. No doubt changes will continue into the future.

EARLY ON EARLY OFF REGIME A considerable period of time during the inquest was spent in relation to evidence being given concerning the so called early on early off regime. The evidence indicated that it was an accepted practice by at least some of the staff members at Quamby to arrive early for the commencement of their shift and for the persons on the preceeding shift to be replaced by those early arrivals and then depart the centre. This is particularly evident on the A shift on the morning of the 17th of September 1996, the date of the second hanging incident involving Mark Watson. On this occasion Mr. Baker, the senior youth worker and supervisor for that shift, contacted Mr. Barnwell well before the end of the shift which was scheduled for 7.00 a.m. to tell him he could go home. He made this call on the basis that Mr. Sherer, who apparently always arrived early for work, was then present in the centre and would go and replace Mr. Barnwell who could then go home.

A number of other witnesses indicated that the regime was not limited to the changeover between the A and B shift but occurred on a regular basis throughout all shifts applicable at Quamby at the time of the death of Mark Watson.

It is difficult in the circumstances to form any concluded view about the extent of the early on early off regime as I did not hear from all employees of Quamby. However, it is clear from the employees that I have heard from that nearly all of them accepted that there was such a procedure in operation as at September 1996 and that it had operated for many years before that date.

Mr. Young, Mr. Woods and Ms. Dabin in her affidavit of the 8th of November 1998, exhibit 275, all denied any knowledge of such a regime.

It might be suggested that a careful perusal of the control room log might have suggested to anyone carrying out that perusal that there was a pattern of early starts and occasionally evidence of early departures. However, it is not clear on the evidence that any of the three management persons whom I have just mentioned ever conducted such an investigation. It appears, therefore, on the evidence that either Mr. Woods, Mr. Young and Ms. Dabin were completely ignorant of the procedure having been totally deceived over long periods of time, in the case of Mr. Young and Ms. Dabin, by the staff or that they chose to turn a blind eye to the existence of a system which in effect did not seriously interfere with the running of the centre but had the potential for catastrophe as was displayed on the morning of the 17th of September 1996.

I am of the view that the evidence does not allow me to form any concluded view as to the knowledge of Mr.

Young, Mr. Woods and Ms. Dabin as to the early on early off regime. I am content to observe that it is clear on the evidence that such a regime did exisit and that it had existed for a long period of time. As to why those in management, particularly Mr. Young and Ms. Dabin, did not discover the existence of such a system which clearly was in breach of the terms of employment of the workers is something the evidence does not allow me to ascertain.

It is clear from the evidence that the system has now been exposed and some steps were taken soon after the death of Mark Watson to ensure that insofar as possible the system was stamped out. It will no doubt require continued endeavours on the part of management to ensure that a corruption of the system such as the early on early off regime does not re-emerge.

LACK OF WRITTEN INSTRUCTIONS I have already commented about the lack of written instructions in relation to manager's instructions such as those given by Mr. Woods on his evidence to Mr. Hess and others concerning the placement and observation of Mark Watson. There are many examples found throughout the evidence to indicate circumstances in which written instructions ought to exist but which for whatever reason cannot be found either because they do not exist or they are lost within the vast paper accumulations that apparently exist at Quamby.

In addition to the lack of written instructions it is clear that there is a complete lack of documentation in relation to activities involving residents at Quamby. As I have mentioned there is no real documentation on the individual dossier of a detainee to indicate what decisions are made about that detainee's placement, either at induction or at any other stage of residence, there is nothing to indicate what decisions have been made concerning any special observations that might be ordered in relation to individual detainees and any explanation as to why such decisions were made. It would seem to be desirable that such information be recorded and kept on individual resident files. It may be that there is a significant need to introduce a compulsory use by the staff of the JIM or similar system to ensure that such material is more easily maintained and more easily accessible to others. The system of merely writing on a white board in the control room would seem to be fraught with difficulty and even danger.

There needs, in my view, to be a reassessment of the procedures followed at Quamby to ensure that there is a process of adequate record keeping and also a process whereby the records are easily accessible to all those members of staff who need to know about individual detainee's requirements. In the case of Mark Watson it is clear that both Mr. Woods and Mr. Hertel had particular knowlege of Mark Watson as a result of their earlier involvement with him but that none of that material was available to anyone who might be making decisions concerning Mark Watson, particularly at the shift supervisor level. I cannot understand, notwithstanding the evidence of Mr. Hertel, why there ought be any limitations on the availability of useful and needed information by all members of staff at Quamby. It seems to be an undesirable situation to allow separate files to be kept by Mr.

Hertel and by the control room. There may be circumstances in which Mr. Hertel is privy to information which might be highly confidential and this, of course, ought be given proper protection, however, it does appear that much of the information available to any of the employees at Quamby must be made available for general usage by all staff members. To restrict their access does, in my view, prevent them from adequately and professionally carrying out their responsibilities.

THE CONTROL ROOM LOG The control room log book was, if not the most significant record at Quamby, then one of the most significant records. The book as I understand it stays permanently within the control room and is supposed to represent the comings and goings at the centre. In addition it records the details of staff movements and handovers at shifts. It is the responsibility of the supervisor or a person appointed by the supervisor to maintain this log accurately. It is the responsibility of the manager to ensure that the log is kept accurately and reflects in a genuine way what purports to be contained in it.

The evidence before me suggests that the control room log cannot be relied upon as an accurate record of what purports to be contained therein. A number of examples were studied during the course of the inquest and I do not intend at this point in time to return to those. It is clear that one example of the failure of the log book to accurately reflect what occurred are the entries at 7.00 a.m. placed by Mr. Baker on the morning of the 17th of September. These were clearly written out in advance and turned out to be absolutely untrue. It would seem to be a critical element of the efficient operation of Quamby that the control room log always accurately reflect what they are required to contain. It is pointless having a system in which the manager merely reads the entries as would seem to be the evidence of Mr. Woods without actually understanding what it is that is there and without realizing the inaccuracies of what is there. Greater diligence is required from at least some supervisors to ensure the control room log is accurately recorded and greater effort is required from the manager to insist that accuracy be maintained.

No doubt there would be scope for the use of the JIM system or some similar system to replace the unreliable control room log book. No doubt such a system would be able to be programmed to ensure that entries are made and must be made on time and are not capable of being easily altered. I understand from the evidence of Mr.

Young that facilities are already available in the control room for access to the JIM system and perhaps it might be useful for there to be a requirement that shift supervisors are adequately trained and then required to use that system. The abolition of the use of such a document as the control room log might well be highly appropriate.

As was stated by Ms. Batzias in her affidavit of the 5th of November 1998, exhibit 274, "Achieving and maintaining standards is a constant challenge for managers and supervisors." This comment is apt and must be borne in mind at all times by those responsible for the management of centres such as Quamby.

SPECIAL OBSERVATION BOOK This book is one of the most critical documents maintained in Quamby. It has been shown even more so than the control room log to be a tissue of lies. I do not intend to revisit the comments that I have already made concerning the special observation book but it is clear that it cannot be relied upon in any way. I understand that since the death of Mark Watson a smart guard system has been installed which requires actual recordings by way of computer of visits by way of observations to units. This, of course, only solves part of the problem in that if

the book is to have any significance at all as a tool for management or the psychologist then those persons must be able to rely with certainty upon the accuracy of the observations contained within the book.

The evidence of Mr. Young and Mr. Woods indicates that there has been a change in the manner of observations being maintained in that there is now a requirement for rotation of officers conducting the observations. This is, no doubt, desirable. There may also be benefit in adequate training of officers required to perform special observations if they had a clear understanding of the role of those special observations. It is clear from the evidence, particularly of Mr. Hertel, that the book has a capacity to be a valuable tool in the hands of management and particularly in the hands of the psychologist. Unless useful observations are entered in the book then the value of it as a tool becomes significantly less. It was not clear from the evidence that all workers regarded the book as anything other than a document required to be completed in some way so as to ensure that there was an entry in each place. It may be that if workers were aware that the book was a significant and valuable tool for the operation of Quamby then they may be more diligent in completing the observations. If such a regime of training is to be put in place then it must inevitably be supported by a system of feed back to officers who ought to be commended for proper work and appropriately dealt with for improper work. If there is no system of this type then it would seem inevitably based upon history that the system will once again fall into disrepute.

I understand from the evidence that a book similar to the special observation book continues to be used at Quamby. If this book is to have any purpose then it must, in combination with the smart guard system, be completed accurately and honestly by workers and, more importantly, supervised by supervisors and management. If workers are not encouraged to do this job properly and at the same time be aware that their work is being scrutinised then it will almost inevitably fall into disrepute again. The Royal Commission Into Deaths In Custody indicated that this area of special observations required very careful and constant supervision in order to ensure that it did not become corrupted. The same must be said in relation to Quamby.

PRODUCTION OF DOCUMENTS UNDER SUBPOENA There were considerable difficulties during the conduct of this inquest in obtaining production of documents both from Quamby and also from the Department. Notwithstanding the fact that subpoenas were issued well in advance of the hearing, documents were still being produced during the hearing. Critical documents were produced within a few days of the end of the hearing.

I am not able on the evidence to form the view that the failure on the part of the Department and Quamby to produce documents in answer to subpoenas reflects anything other than an element of inefficiency, particularly at Quamby. It would seem on the evidence that there is, particularly at Quamby, a vast supply of documents and the evidence indicates that the response to the subpoenas required some five staff members engaged for a number of days. It is extraordinary that such a volume of documentation exists much of which would seem to be less than useful when carefully looked at. Alternatively, much of the documentation that was critical seemed to be difficult to find.

I am not prepared in the circumstances to make any finding as to why the documentation was produced in such a way but it is clear that there needs to be consideration, particularly by Quamby, as to the administrative system that operates at the centre.

SUMMARY Mark Watson was arrested on the 13th of June 1996 and placed in Quamby. He was 17 years of age and the evidence indicates that for many years he had had some difficulty in coping at school and was developing, at the time of the offence, a problem with drugs. The incident which led to his arrest involved a dispute between himself, his mother and his mother's defacto husband. It appears on the evidence that at the date of his arrest the relations between himself and his mother were extremely strained. It would also appear from the evidence that at the time of his arrest, and more particularly subsequent to his arrest, the relationship between himself and his father, at least from the point of view of Mark Watson, were difficult. His father had, correctly in my view, attempted to obtain treatment for his son and it would seem that his son did not appreciate the efforts being made by his father for his benefit.

He was a resident at Quamby from the 13th of June 1996 until the 24th of June 1996.

FIRST REMAND IN QUAMBY The evidence indicates during this period that Mark Watson was a very troubled young man. He had the pressures of his family estrangement and also a difficulty in coping with the fact that his girlfriend was at that time about to leave Australia and he was anxious but unable to see her before her departure. This combination of factors appears to have caused concern in relation to his management but he seems to have been generally successfully dealt with at Quamby during that period. It is very difficult to obtain from the material presented at the inquest a clear picture of the manner in which he was dealt with during the whole of his stay in Quamby on this first occasion.

Any attempt to ascertain from the evidence what was occurring in relation to Mark Watson requires a time consuming and confusing search through various documents including the individual dossier, the handover sheets, control room log and the special observation book. Even this time consuming effort does not reveal with any clarity any of the decision making processes which were occurring in relation to the placement, observations and supervision of Mark Watson during his first remand period. There is nothing to indicate where he was initially housed and what observations were to be undertaken in relation to him and if any special observations were to be undertaken what the nature of those observations were. The best that can be said is that in the absence of any record of special observations one must accept that he was admitted into Quamby as a person who required no special consideration immediately upon his admission.

This circumstance would seem to indicate a failure on the part of the system to have in place procedures which allow the persons responsible for the induction process to be aware of any relevant history. Such relevant history was, of course, in the possession of Mr. Woods and Mr. Hertel but not in the possession of the person or persons who made the initial decisions. It is also not clear whether the material prepared by the police at the time of arrest was available to the persons making those initial decisions. While nothing flowed from this absence of information on this occasion it is clear that there is a need for the persons making decisions effecting the safety of young people in Quamby to have available to them any relevant information which would assist in making the decision making process more informed and less speculative.

It is also clear from the evidence that there needs to be more information relating to the residency of a young person in Quamby to be documented and maintained upon the personal dossier of the resident so as to enable meaningful and easy access by other members of staff. It is entirely inappropriate for the principal source of information concerning a resident to be the white board in the control room. It is essential that all decisions concerning placement and observations and any other relevant activities relating to a resident be recorded either in the dossier or alternatively, if more appropriate, on the JIM system or similar.

PERIOD BETWEEN FIRST RELEASE FROM QUAMBY AND ADMISSION TO THE CANBERRA HOSPITAL Mark Watson was released on bail on the 24th of June 1996 and admitted to The Canberra Hospital on the 10th of July 1996. During this period he attempted to undergo treatment in relation to his developing drug problem but seems to have been unsuccessful in institutionalised treatment. During this period he remained in contact with Ms. Flynn but his situation generally appears to have deteriorated. He ultimately came into contact with Ms. Shaw and Ms. Cusack and as a result of their concerns was taken by them to the hospital where he was subsequently admitted.

ADMISSION TO THE CANBERRA HOSPITAL Mark Watson was examined by Dr. Westcombe upon his presentation at the hospital on the 10th of July 1996 and following Dr. Westcombe's assessment he was admitted overnight. Dr. Westcombe made his decision on that occasion on the basis of the fact that Mark Watson had nowhere to go and that he appeared depressed.

Additionally, he was happy to be admitted.

Mark Watson was re-examined the next morning by Dr. Burnand and she, applying appropriate criteria, was of the view that it was not appropriate to maintain the admission and Mark Watson was discharged into the custody of the AFP.

There is nothing in the evidence relating to the first admission to the hospital which would allow any adverse comment to be made concerning any of those involved. The evidence clearly indicates that Ms. Shore and Ms.

Cusack acted appropriately and with diligence. The evidence also indicates that Drs. Westcombe, Burnand and Hughson acted appropriately in their professional capacities in the interests of the young person as he presented to them. There is no ground for criticising any of the medical practitioners. Some concerns were raised during the evidence of the medical practitioners concerning possible bed shortages at the psychiatric unit of the hospital. It

is not appropriate for me to make any comment concerning this as it is clear that it was not a factor that influenced the decision making process that resulted in the admission of Mark Watson.

The circumstances of the admission of Mark Watson to the hospital on the 10th of July 1996 do, however, raise the need for some form of accommodation between Quamby and a hospital which has a capacity to deal with young people like Mark Watson who have a complicated personal situation. It is no doubt true that very few, if any, young people happily go into Quamby but it is clear that there are at least a number, and perhaps regrettably an increasing number, of young people who present at Quamby with problems similar to those experienced by Mark Watson and who are not best placed in Quamby. It is also clear that it is not appropriate for them to be placed in a psychiatric hospital for the reasons advanced by the medical practitioners in this inquest. It is clear, however, that there is a need for protection both of the young people and the community which may well be best dealt with by having a discrete facility either attached to The Canberra Hospital or some other institution which is largely medical in nature but also provides security. This environment would, in my view, be advantageous to the community in handling the types of issues raised in the circumstances of Mark Watson.

PERIOD BETWEEN ADMISSION TO THE CANBERRA HOSPITAL AND SECOND REMAND PERIOD AT QUAMBY Mark Watson returned to the Children's Court on the 11th of July 1996 and was granted bail with certain conditions. Amongst those conditions was that he was required to be subject to supervision by the Director of Family Services and this order caused him to come into contact with Ms. Uhle. It is clear from the evidence that between his release on bail on the 11th of July 1996 and his re-entry into Quamby on the 13th of September efforts were made by Ms. Uhle and others to attempt to put together some program for the benefit of Mark Watson. The evidence indicates that these attempts were not successful at least in part as a result of inadequate resources being available to those involved in the attempts. It is difficult on the evidence before me to make any particular recommendation concerning resources in this area but it is clear that young people such as Mark Watson present a substantial demand upon resources of all types in the community. There is a need in those circumstances for the service providers to be able, with confidence, to deal in an appropriate and expeditious manner with the requirements for support required by young people. No criticism can be made of Ms. Uhle or others involved in this period, but it is clear that if there had been more substantial resources available to Ms.

Uhle and others then a program may have been instituted with greater speed than occurred in this particular circumstance.

SECOND REMAND IN QUAMBY 13 SEPTEMBER 1996 TO 15 SEPTEMBER 1996 These few days indicate clearly the role of youth workers and the relationship of youth workers to managers in carrying out the duties and responsibilities in relation to the care and safety of residents at Quamby. The actions of Ms. Masters-Smith, a youth worker and Mr. Withers, the shift supervisor, clearly indicate how events occur at Quamby but also indicate the problems in relation to the recording of such events and the reasons for them.

There is once again a lack of clear documentary evidence to show what occurred to Mark Watson and why it occurred.

RESPONSE TO THE INCIDENT OF THE 15TH OF SEPTEMBER 1996 The evidence relating to the attempted hanging of the 15th of September reveals the best and worst of the system as it operated in Quamby at that time. The conduct of Ms. Rowan and Mr. Shore represented the way the system ought to operate. Ms. Rowan, in particular, notwithstanding standing orders concerning a limitation or a restriction on her entering a unit by herself, did so and is to be commended for her actions. The rule relating to the restriction of entry into a unit, while it may in some circumstances be appropriate, clearly is inappropriate in emergency situations and it ought to be made clear that a worker on the floor has an unlimited discretion and will be supported by management in the exercise of that unlimited discretion in circumstances where it is clear that instant action must be taken. If Ms. Rowan had complied with the restrictive rules on this evening it may well be that the death of Mark Watson would have occurred that day rather than some days later.

The actions on the part of Ms. Rowan and Mr. Shore represents, in my view, the best of the system at Quamby.

The response by Mr. Mewburn, Mr. Young and Mr. Woods represents the worst of Quamby at that time. Mr.

Mewburn seems to have taken little part in the activities other than to remain stationed in the control room. He did make contact with the Mental Health Crisis Team but the evidence would suggest he did this only under instructions. The evidence concerning his attempts to contact the parents would seem to suggest that if he did make such an attempt then it was without any success at all. The evidence would suggest that he may not have made such an attempt notwithstanding Ms. Hillhorst's memory.

The failures by Mr. Woods and Mr. Young to cause any checks to be made in relation to the room or to seek any detailed advice as to the circumstances of the hanging must be subject to substantial criticism.

Ms. Hillhorst, in my view, conducted herself appropriately but the requirement for the on call manager to report directly to Mr. Young is entirely inappropriate and ought end forthwith. This process clearly caused Mr. Woods, in particular, to neglect his responsibilities in relation to the management of Quamby. It also allowed Mr. Young to operate on the basis that it was not his responsibility to conduct the intense investigation which was clearly called for following the incident of the 15th of September.

The Mental Health Crisis Team, which consisted of Ms. Rees and Ms. Napier, clearly conducted themselves appropriately and the only comment I would make about their involvement is that it would seem to be appropriate that any information obtained by members of such a team ought to be communicated in substantial detail to the relevant persons at Quamby so that they are more clearly aware of the events which caused the Mental Health Crisis Team to become involved. It is clear on the evidence that Ms. Napier, in particular, had a much clearer understanding of the state of mind of Mark Watson and also of the mechanism relating to his attempted hanging.

It is not clear on the evidence that this information in its detail was passed on to anyone. I am not being critical of Ms. Napier in relation to this as there may be restrictions upon her communication and indeed she may have passed information to the staff and it was not acted upon. I am of the view that it is essential that all information, however it is obtained in relation to incidents of this sort, must be brought to the notice of those who are responsible for the care and safety of young people in Quamby.

Mr. Young and Mr. Woods both failed in their responsibilities to respond appropriately to the attempted hanging on the 15th of September. I have listed in detail my concerns in relation to those two gentlemen and do not intend to repeat them in this summary. The events of the morning of the 16th of September would suggest that there is a need for greater care in relation to the preparation of documents, particularly incident reports. Incident reports are an essential tool in relation to the appropriate administration of Quamby. There seems to be a lack of understanding of the process involved in preparing such reports and their collation and distribution. There needs to be introduced a clear system in which reports are properly prepared by appropriate people and properly brought to the attention of those who need to know. There is also a need for any response to those reports to be communicated back to the author of the report so that they are aware of that response and more adequately able to properly perform their role at Quamby.

I do not believe that it is appropriate to be critical of Mr. Hertel in relation to his role on the 15th and 16th of September as it is clear that he was only called in at the last minute to facilitate the transport of Mark Watson to court and then to hospital. While it might be said that Mr. Hertel could have taken a more active role at this particular time I do not believe that such a role was contemplated by himself or by Mr. Young.

SECOND VISIT TO THE CANBERRA HOSPITAL Mark Watson returned to the hospital on the 16th of September 1996 and was examined once again by Dr.

Westcombe. Dr. Westcombe had a distinct advantage at this time in that he had previously dealt with Mark Watson during his admission in July 1996. He was able to clearly recall Mark from that earlier occasion and was able to use that experience to compare the presentation of Mark in July 1996 as against his presentation in September 1996. As a result of his assessment he declined to admit Mark Watson to hospital on this occasion.

His view at this time was that unlike the July admission there was no problem about accommodation, however unsatisfactory Quamby may have been, and that there were no symptoms to suggest a depressed situation such as had existed in June 1996. One element of uncertainty in relation to the hospital examination of the 16th of September is that I am not aware what information, if any, Ms. Napier had passed on to Dr. Westcombe.

Notwithstanding this it is clear on the evidence that Dr. Westcombe operated at that time on the basis of his assessment of Mark Watson as he presented on that day. Once again the issue concerning bed availability was raised but it is clear from Dr. Westcombe's evidence that this was not a factor in his decision making process. It is clear from Dr. Westcombe's evidence that he was of the view that the presentation of Mark Watson on that day was not such as required his admission to the psychiatric unit at the hospital.

There is nothing in the evidence which would require me to be critical of Dr. Westcombe. In my view Dr.

Westcombe conducted himself appropriately and professionally and made a clinical judgment which was clearly open to him upon the evidence. The fact that Mark Watson subsequently hung himself again is not in any way, in my view, the result of any failure on the part of Dr. Westcombe to properly carry out his responsibilities. The psychiatric ward at The Canberra Hospital is not provided by the community to allow persons who are unhappy at Quamby to obtain admission to a more desirable institution. It is there to provide appropriate assistance for those deemed by the medical staff to require admission. It is clear from Dr. Westcombe's evidence that the death of Mark Watson has had a traumatic impact upon him. This, of course, is understandable but I am of the view that there is nothing in the evidence that suggests that Dr. Westcombe made other than a correct professional decision.

THE RETURN TO QUAMBY Mark Watson returned to Quamby in the mid-afternoon of the 16th of September 1996. The circumstances of his return to Quamby exposed further problems in relation to the administration of the centre. Mr. Woods was absent from his office being engaged in some staffing exercise in another part of the city. Mr. Young appears to have been present at his work but was not involved in anything that occurred upon Mark's return. Mr. Hertel, who had become involved in the morning, and who had had substantial contact and experience of Mark Watson, became aware of additional information during the course of the afternoon but does not appear to have passed on any of that information in any useful way to any of those who were responsible for the supervision of Mark Watson during the ensuing day. He was in a "management position" at that time but did not assume any management role and clearly allowed the system to operate in its own way. This failure on the part of Mr. Hertel while it cannot be said that it impacted directly upon the situation of Mark Watson clearly did not assist in the heightening of awareness which was clearly required by the staff at this time.

Mark Watson was allowed to return to the same unit which he had occupied at the time of his first attempted hanging; a unit which had not been inspected in any way by anyone following that event. There was, of course, the cursory examination by Mr. Shore to remove certain items but there was no real inspection of the room to attempt to ascertain how it was that the incident of the 15th of September had occurred. This failure is, of course, critical.

The simple fact is that upon his return to Quamby Mark Watson was placed in one of the units which were regarded as the safest and most secure and was subject to the continuation of the five minute observations which had been imposed by Ms. Hillhorst following the 15th of September incident. This as I understand the evidence was the highest level of safety and security available at Quamby.

The events of the return of Mark Watson to Quamby clearly expose again the complete failure of proper documentation in relation to what occurs at Quamby at all levels. Mr. Hertel, while he wrote a psychologist's instruction did not take any immediate action to ensure that this was drawn to the attention of anyone who may have benefited from his views. It lay on the floor of Mr. Woods' office awaiting further consideration.

Subsequently it seems to have been placed, with the approval of Mr. Woods, on the manager's instruction book at a time when Mark Watson had already been taken to hospital following his hanging on the 17th of September.

It is unclear as to why this occurred. There is also a complete lack of any written instructions of any useful nature in relation to any instructions given by Mr. Hertel to the shift supervisor upon Mark Watson's return. This, of course, is a matter for criticism.

The evidence concerning the return to Quamby again also exposed the corruption of the special observation regime. It is in no way clear that Mr. Dugan conducted the observations that he suggested he did and it is certainly clear that Mr. Barnwell did not.

THE EVENING OF THE 16TH/17TH OF SEPTEMBER 1996 The events of the evening and morning of this day reveal once again the best and worst of the system as it operated at Quamby. Regrettably on this occasion more of the worst of the operations at Quamby are exposed.

The best of Quamby is exampled by the conduct of Mr. Withers who, although clearly part of the early on early off regime, acted commendably once he became aware of the problem involving Mark Watson. While I have indicated that he was part of the early on early off regime it is not in all of the circumstances I think appropriate to be too critical of Mr. Withers for allowing Mr. Baker to leave his post prior to the 7.00 a.m. handover and for allowing Mr. Baker to arrange for the departure of Mr. Barnwell prior to the end of his shift. It is, of course, inevitable that some criticism be directed at Mr. Withers for this failure as if the handover had occurred at the proper time then the dereliction of duty by Mr. Baker and Mr. Barnwell would not have occurred. That is to say, if Mr. Baker had remained at his post and Mr. Barnwell had remained at his post then one would assume that such a situation would have reflected a greater element of diligence on the part of Mr. Barnwell in carrying out the observations. However, even if the early on early off regime had not existed then there would be no guarantee that Mr. Barnwell would have carried out the observations correctly. Notwithstanding this element of criticism of Mr. Withers it is clear as I have said that once he became involved in the incident he conducted himself commendably and with a disregard for his own circumstances did all that he possibly could to assist Mark Watson. In relation to the events after the discovery of Mark Watson hanging in the special needs unit it is clear that Mr. Sherer, Mr. Bennett and to some extent even Mr. Barnwell did what they thought was appropriate to provide assistance to Mark Watson.

The senior youth worker in charge of the shift on this evening, Mr. Daniel Baker, clearly was derelict in his responsibilities in relation to the safety and care of Mark Watson and failed totally to supervise Mr. Barnwell to ensure that he carried out his duties. Mr. Baker was an unreliable witness and clearly attempted in his evidence

to obscure the fact that he left his post prior to the appropriate time and also that he encouraged Mr. Barnwell to do the same.

Ms. Dillon was the second worker, along with Mr. Barnwell, on that shift and while she had no direct responsibility in relation to the observations of Mark Watson she did have an overall responsibility in relation to the safety of all residents at Quamby that evening. I am not able with any confidence to find that she did carry out her responsibilities properly on that evening and it is also clear that she left prior to the end of her shift. She was also an unimpressive witness and I am not convinced that there was not some element of discussion at some point in time between herself, Mr. Baker and Mr. Barnwell as to the evidence that might be given to this inquest. There was clearly a number of discussions between those parties but the evidence does not allow me to form a definite view as to the reason for these discussions. It is, however, remarkably coincidental that both she and Mr. Baker relied upon the inaccuracy of the clock to explain away their early departure from their posts.

IAN WILLIAM BARNWELL Mr. Barnwell is, of course, the most culpable person in relation to the evidence given at this inquest. He was an active participant in the early on early off regime and appears on much of the evidence to have been engaged in a long standing battle with management. It is not appropriate, as I have indicated, for me to go into this in any detail but it is clear that there was animosity between Mr. Barnwell and many other members of the staff and management at Quamby. Mr. Barnwell was one of the most experienced officers employed at Quamby and clearly one upon whom little reliance could be placed. It is concerning, upon reviewing the evidence, to see a pattern in relation to those who gave evidence that the longer they were employed at Quamby the more inefficient they became. Those who have conducted themselves commendably in relation to the residency of Mark Watson at Quamby seem more often than not to be junior and inexperienced officers. The only exception of this is the conduct of Mr. Withers. Even with Mr. Withers, as I have said, he was part of the system particularly in relation to the early on early off regime. This evidence would tend to indicate the need as has been expressed by a number of witnesses for a very close and ongoing supervision and training regime so as to ensure that all employees at Quamby, whatever their level, continue to operate at an appropriate level of efficiency and not fall into bad habits that become exaggerated over time.

It is clear on the evidence that Mr. Barnwell did not conduct observations appropriately during the whole of the evening. It is also clear that he did not conduct any observations from around about 6.30 in the morning and possibly as early as 6.25. I am not on the evidence able to form any view as to whether he conducted any observations during the course of the evening. It is clear from the evidence that during part of the evening he was asleep, for another part of the evening he was absent from the six bed unit in the control room and for a large portion of the evening was engaged in the preparation of the medication satchels.

CHRISTOPHER JOHN WITHERS Mr. Withers was the shift supervisor for the B shift commencing at 7.00 a.m. on the 17th of September 1996 and took over from Mr. Baker on that morning. It is clear on the evidence that Mr. Withers was a participant in the early on early off regime but it is not clear from the evidence whether he had any capacity to prevent Mr. Baker from leaving at the early time that he did. Mr. Withers was as I understand it senior in a general sense to Mr.

Baker but there is no evidence of the capacity of a worker in Mr. Withers' situation to control a worker in Mr.

Baker's situation. There is some evidence given by Mr. Withers to suggest that Mr. Baker did not have a capacity to order Mr. Sherer to go and relieve Mr. Barnwell and if this is correct then there may have been some difficulty in Mr. Withers ordering Mr. Baker to stay until the end of the shift. Ultimately it is a matter for further review by the Quamby administration to clarify whether someone in Mr. Withers' situation ought to have a capacity to require an outgoing shift supervisor to stay until the formal end of the shift.

While there may be no evidence at this time as to Mr. Withers' work place capacity to direct Mr. Baker, it is clear on the evidence that incidents of the type which occurred on this morning in furtherance of the early on early off regime were not unusual. It would be clear, therefore, that whatever Mr. Withers' legal capacity to direct Mr.

Baker may have been, he would have been aware from personal experience of Mr. Baker's abandonment of his office at an early hour. This ought to have been reported by Mr. Withers to management. There is no evidence before me to suggest that such a report was ever made.

Mr. Withers first became aware of a difficulty with Mark Watson at about 6.40 a.m. and responded correctly to the call for assistance from Mr. Sherer.

IAN CRAIG SHERER Mr. Sherer was a participant in the early on early off regime and would seem to have been substantially exploited by reason of the fact that he had a habit of turning up to work much earlier than other members of his shift. He was, in my view, entitled to reject the direction given to him by Mr. Baker to relieve Mr. Barnwell earlier than the end of the shift. He ultimately succumbed to the pressure imposed on him by Mr. Baker and did go to relieve Mr.

Barnwell. While it is clear that there was a delay before he commenced his observations there is nothing in the evidence that would indicate he had any reason to assume that there was any urgency about him commencing these observations. He was entitled to presume that Mr. Barnwell had been properly carrying out his duties and that in those circumstances there was still a period of time available to him before the next five minute observation was required. Once Mr. Sherer discovered the situation with Mark Watson he acted appropriately and clearly did all that was required of him to assist in the emergency situation.

MARK GERARD BENNETT Mr. Bennett was a member of the shift which was to take over the responsibility for the care and safety of the residents at Quamby at 7.00 a.m. on the 17th of September 1996. He had arrived early at work and was present when the emergency developed. He assisted appropriately in relation to the emergency and was responsible for calling the ambulance. There is nothing about the conduct of Mr. Bennett on this date that would warrant any critical comment.

THE AMBULANCE SERVICE The ambulance was called at 6.51 a.m. on the 17th of September 1996 and arrived promptly at 6.58 a.m. Ms.

Edwards and her co-paramedic, Mr. Edwards, on the evidence did all that was conceivably possible to assist Mark Watson. The medical evidence suggests that at the time of their arrival his situation was terminal.

It is clear on the evidence of Mr. Edwards and Ms. Edwards that there was a substantial degree of confusion in relation to their attempts to obtain a history concerning the events of that morning but notwithstanding this confusion they both attempted to carry out their duties and did carry out their duties in a proper and professional manner.

QUAMBY YOUTH DETENTION CENTRE The Quamby Youth Detention Centre had its beginning as a shelter for children in 1962. It continued in this role until 1988 when it began to accept not only children remanded to a place of safety but also children who had been committed to an institution in relation to criminal offences committed in the Territory. The evidence before the inquest would indicate that this change in 1988 created a series of problem which have continued to bedevil the proper management of Quamby. There is within Quamby at this time a range of residents that one would not normally find together in one institution in any other place. The fact that there exists within the Territory only one institution for children creates a situation in which the mixing of male and female residents of various ages and experiences creates a substantial challenge for management and staff. There is clear evidence that there has been over the years a substantial number of inquiries into the running of Quamby and it is also clear that there has been an ongoing disquiet on the part of staff concerning the operations of Quamby. As I have indicated previously it is not my role to inquire into these areas of disquiet but it is clear that the dynamics of Quamby create very substantial problems for the day to day management of the centre.

There is a substantial need, in my view, for a careful study by the Government as to whether it is desirable for the intermixing of residents which occurs at Quamby to continue. It would seem, based upon the minimal evidence before me, that it may well be undesirable but I am not in a position to usefully reach a final conclusion.

One other matter which ought to be raised at this point is that there may be benefits to be gained if there is only one government division responsible for all corrections in the Territory. This matter was canvassed to some extent in the inquest into the death of Shannon Robert Camden and was raised with Mr. Young during his evidence. I accept that there are no doubt arguments for and against such a proposal and I have clearly not heard evidence in any detail for or against the creation and operation of one single corrections division. However, there does seem to be a need within the Territory to have a clear policy administered by a central organisation, particularly in relation to the administration of all correctional facilities. I have had the melancholy duty to conduct inquests into the deaths of two young men, both of whom died by hanging, one in the Belconnen Remand Centre and one in the Quamby Youth Detention Centre. Both deaths have a substantial number of similarities particularly in relation to the administration of the individual centres. Both had problems in relation to accurate record keeping and staff supervision. It is not appropriate for me to go in any detail into the two inquests other than to say in my opinion it is clear that within the correctional requirements of the Territory there is little basis for

two separate administrations. There are no doubt different considerations applicable to the running of a youth detention centre than there is of a remand centre or prison but it is clear that there must be a similarity of requirements as to administration. I believe it would be useful for the Government to inquire as to whether it is feasible to have a central corrections unit within a department and that the administration of all correctional facilities within the Territory be controlled by that one unit.

It has to be accepted as a fact that Quamby has both correctional and rehabilitative elements and the tensions caused by these two elements will need to be resolved. I have no evidence before me upon which I would be able to make any suggestion as to how this might occur but it is clear from the evidence heard in this inquest that if that tension is not dealt with then the problems exposed will continue to develop and will ultimately re-emerge in much the same way as they did in September 1996.

The history of departmental control of Quamby as outlined by Mr. Young suggests that there has been a lack of a consistent policy on how best to manage the institution. This situation has to some extent now been remedied by changes implemented since the Stevenson Report, but I have a concern that the underlying dynamics of the mixture of people at Quamby has not been properly considered by those who have the responsibility to do so.

KEYS It is clear on the evidence that the policy relating to keys is flawed. This issue was raised as long ago as 1994 by Mr. Aldcroft and subsequently in the 1995 Review. It is clear on the evidence that the policy was designed to protect the staff without proper consideration being given to the safety of the residents. The lack of clarity and in particular the lack of any written instruction concerning the operation of the keys policy was also flawed. It is clear on the evidence that workers, particularly on the night shift where it seems greater risks to safety exist, must have immediate access to keys to enable them to enter the units. This need for a policy change goes hand in hand with a need for a policy clarification which I have already mentioned concerning the right of an individual worker to enter a room in the case of an emergency. I accept that this change in policy may on occasions expose a youth worker or some other worker to false allegations but it seems to me on balance that the interests of the residents must take precedents over any other consideration.

SUPERVISION/MANAGEMENT The evidence before this inquest clearly indicates that the management structure at Quamby was inadequate.

Mr. Young had a significant role in the day to day management and it is clear from the evidence that his personal situation caused a confusion of responsibility such as occurred on the morning of the 16th of September 1996. It is also clear from the evidence that the immediate supervisor of the shift, Mr. Baker, was inadequate and failed in his responsibilities. Mr. Woods, for reasons that I have already indicated, was responsible for a large number of failures and omissions in his role as acting manager, but it is clear that at that time he was carrying out his duties under a substantial disadvantage.

It is not appropriate, in my view, that there exists at Quamby a role for a person such as Mr. Young. It must be made clear that the manager of Quamby has full responsibility for the whole of the management and there cannot be any circumstance in which a manager is able to evade those responsibilities by implying that someone holding down the office of director, however described, is responsible for the management. There must be a supervisor for the manager but this must be a role in which that supervisor supervises from a distance and not from an immediate hands on type of situation.

The other significant factor in relation to the management is the on call duty manager system which clearly is inappropriate. If the system is to operate in a way similar to the system that operated in September 1996 then it would be essential that the person acting as the on call duty manager reports only to the manager and to no other person. It is clear that if this situation does not exist then problems similar to those that arose on the 16th of September 1996 will re-occur.

STAFF PROBLEMS The evidence indicates a long history of staff problems at Quamby many of which have arisen as a result of the difficulties in managing the mix of residents in the centre. There are clearly other basis for dispute between staff and management which will need to be considered by those responsible for the administration of Quamby. I accept that considerable change has occurred in relation to staffing since the death of Mark Watson and that this change is continuing. It is to be hoped that these changes eliminate entirely the problems that have occurred in the past but it is clear that there must be ongoing efforts made, particularly by management, to ensure that whatever changes are made remain in place and the problems exposed as the result of the death of Mark Watson do not re-emerge.

EARLY ON EARLY OFF REGIME There is no doubt that the general body of evidence indicates that there was a wide spread procedure whereby people left their shift early and were replaced by oncoming shift workers. It is not clear that this always occurred in the sense that there is a suggestion that on occasions people left their shift and were not replaced immediately. It is also clear from the evidence that the exposure of this regime during the inquest have led to changes in the operation of Quamby to ensure that the system does not continue or re-emerge.

LACK OF WRITTEN INSTRUCTIONS One of the most significant matters to come out of this inquest was the complete lack of any instructions either in the practice and procedure manual or elsewhere to clearly indicate to workers at all levels what it was that they were required to record and perhaps even more importantly why they are required to make such a record. Even if there were written instructions the evidence indicates that there was a huge volume of information transmitted orally. Also there was present in the control room a white board which seemed to contain much information which in theory ought to have been reduced to writing. There is a clear need for an urgent review of the processes in Quamby so as to ensure that there is available to any worker clear written instructions as to the responsibilities of each worker and clear instructions as to supervision and care of each individual resident. This can be done either in written form as currently is the case or by the creation of an appropriate program on the computer with appropriate machinery and training and a compulsory requirement for all workers to use the system.

CONTROL ROOM LOG The control room log book was for practical purposes a document studded with inaccuracy and lies. If it is to have a significant role in the future then it must be honestly completed and rigorously supervised. The same comment applies to the special observation book.

MICHAEL JOSEPH WHITE Mr. White is the Executive Director of Children Youth and Family Services Bureau which is part of the Department of Education and Training. Mr. White in his statement to the inquest, exhibit 276, indicates that he was appointed to that position in July 1996. One of the services provided under the umbrella of the Children Youth and Family Services Bureau included the facility at Quamby.

Mr. White indicates in his statement that he had been in his position for ten weeks when Mark Watson committed suicide. He indicates that he was not familiar with the operations of Quamby but was concerned that such an event had occurred and he initiated a review to examine the circumstances in which it had occurred. It appears that the death of Mark Watson galvanised Mr. White and his Department into confronting the problems which had simmered at Quamby for many years. It is, of course, not fair to blame Mr. White for this inaction as he had only been in his position for a relatively short period of time. His situation is in many ways similar to that confronting Mr. Woods.

It is clear from his statement and from his evidence that as a result of his concern about the death of Mark Watson that a great many changes have resulted in the operation at Quamby. It is not necessary for me to go into these changes as I intend to send a copy of his statement to the Attorney-General as part of my overall report but it is important to indicate some of the changes that have occurred.

There have been changes in relation to the leadership at Quamby in particular relating to Mr. Young and changes relating to the culture at Quamby. Additionally there have been changes by way of increase to the budget allocation for the operation of the centre particularly in relation to staff and related costs. Physical changes have occurred with the introduction of the smart guard system and electronic striking mechanisms for the doors of the six bed unit. Many other changes have occurred and Mr. White indicates in his statement that these changes will continue.

As one of the actions taken by Mr. White following the death of Mark Watson a performance review took place which is known as the Stevenson Report, exhibit 234. In this Report some 27 recommendations are made. I accept that much of what was done by the Stevenson Report is outside the scope of this inquest but my perusal of the recommendations indicate that there is nothing within those recommendations that I would not support based upon the evidence given to the inquest.

The evidence of Mr. White indicates, in my view, that he on behalf of his Department now have a much clearer understanding of the problems and the reasons for those problems which have existed at Quamby for a long period of time. It is to be hoped that the resolve indicated in his statement and his evidence continues with proper

financial support from Government to ensure that the necessary changes are made and that a system is put in place which ensures that the changes made continue for the benefit of future residents at Quamby. It is, of course, a great tragedy that it required the death of a young man to trigger the sort of action taken by Mr. White.

Nothing had changed at Quamby apart from the death of Mark Watson over a considerable period of years and that situation was clearly known to those responsible in an administrative way for the conduct of Quamby. The fact that all of this action has been taken as a result of the death of a young man merely indicates that it ought to have been taken much earlier.

FINDINGS, RECOMMENDATIONS AND COMMENTS

1. FINDINGS I am required under section 56 of the Act to find, if possible, "(a) the identity of the deceased;

(b) how, when and where the death occurred;

(c) the cause of death;

(d) the identity of any person who contributed to the death".

I, accordingly, make the following findings:

(a) The deceased was Mark Robert Watson.

(b) The deceased died from cerebral ischaemia at The Canberra Hospital at 2.45 p.m. on the 21st of September 1996.

(c) Death was caused by brain death caused by cerebral ischaemia caused by hanging of the deceased which occurred at the Quamby Youth Detention Centre at about 6.30 a.m. on the 17th of September 1996.

(d) Subsection (d) of section 56 requires that I shall find, if possible, the identity of any person who contributed to the death of the deceased. For reasons which I will go into in more detail in my comments concerning section 24 of the Act I am not prepared to find that any person contributed to the death of the deceased.

I shall return in due course to make comments under the provisions of section 56(4) and section 58, but at this point in time turn to consider the provisions of section 24. Section 24 of the Act is in the following terms: "The Coroner holding an inquest into a death in custody shall include in a record of the proceedings of the inquest findings as to the quality of care, treatment and supervision of the deceased person which, in the opinion of the Coroner, contributed to the cause of death." It is my view of the evidence and my reading of the Act that it is more appropriate to make a finding as to the contribution to the cause of death in relation to the deceased than it is to make a finding in relation to the contribution to the death of the deceased.

The evidence concerning the failures on the part of workers and management at Quamby does not, in my view, amount to a circumstance in which I could find any of those persons "contributed to the death" of the deceased, but in my view it is clear that they contributed to the cause of death.

The death of Mark Watson arose as the result of him hanging himself in unit 605 in the special needs unit at the Quamby Youth Detention Centre in the early morning of the 17th of September 1996. I am not able to find a precise time of the hanging, but the evidence of Professor Herdson suggests that it occurred around 6.30 a.m. on the morning of the 17th of September 1996.

Mark Watson was taken by ambulance to The Canberra Hospital (formerly the Woden Valley Hospital) where he was admitted and died at 2.45 p.m. on the 21st of September 1996. A report provided by Dr. Thomas Lo, exhibit 10, states as follows:

"I attended to Mark Watson on 21/9/96 prior to his death in the intensive care unit of The Canberra Hospital. He was admitted to ICU on the morning of 17th September 1996 following a cardiac arrest as a consequence of hanging at Quamby Youth Centre. According to the admission notes, he had a Glascow Coma Score of 3 out of fifteen on admission. A diagnosis of hypoxic brain injury, and cardiac arrest was made by the attending doctors as (sic) the time.

I first looked after Mr. Watson on 20th September, and at that time he was paralysed and heavily sedated as part of the management of his cerebral oedema secondary to hypoxic brain injury." At the time of his hanging he had been at the Quamby Youth Detention Centre on two separate occasions, the first in June 1996 and the second between the 13th and 17th of September 1996. He had been charged with a number of offences relating to an incident involving his mother and her defacto husband and at the time of his death was awaiting trail in relation to those charges. He had pleaded not guilty to the charges.

The quality of care, treatment and supervision of Mark Watson encompasses more than his supervision by the workers and management at Quamby. I accept on the evidence that it is not possible to say that any person or organisation or the lack of care, treatment and supervision of any person or organisation other than a worker and the management of Quamby in any way contributed to the cause of death of Mark Watson.

There was some comment made in relation to the non-admission of Mark Watson to The Canberra Hospital on the 16th of September 1996 and although not directly suggested it was implied that the failure on the part of Dr.

Westcombe to admit Mark Watson on this occasion may amount to a circumstance which could lead to a finding that Dr. Westcombe had contributed to the cause of death of the deceased. I am of the view that no criticism at all can be leveled at Dr. Westcombe in relation to his non-admission of Mark Watson on this occasion. It is not in my view the role of any hospital to admit persons to a psychiatric unit other than in circumstances where they are suffering from an appropriate psychiatric condition. There may be exceptions to this particular view, but the circumstances of the presentation of Mark Watson on that day do not in my view of the evidence provide an exception to that rule. There is nothing about the conduct of Dr. Westcombe in either his examination or his decision making process that would require me to be in any way critical of him and it is certainly clear on the evidence that he did not in any way contribute to the cause of death of Mark Watson.

It may well be, and I will comment again in due course, that there is a need for a facility within the Territory which can deal with persons involved in the criminal justice system in a way that does provide surroundings more similar to a hospital than to a custodial institution. It is clear, however, that this is not the role of The Canberra Hospital.

In my opinion the only persons to whom one might look for a finding that they contributed to the cause of death of Mark Watson are those involved at Quamby. I will look at those individually at this point.

IAN WILLIAM BARNWELL It is clear on the evidence that Mr. Barnwell did not conduct the observations as he was required to do on the evening and morning of the 16th/17th of September 1996. It is clear that on that night and morning Mark Watson was a very vulnerable young man. He had already attempted to hang himself on the evening of the 15th of September 1996 and had been rejected by the hospital for admission. His circumstances it seems on the evidence had deteriorated over the period between his first admission in June 1996 and his last admission to Quamby in September 1996. He was the subject of the most careful regime available at Quamby. That is to say that he was in the special needs unit, regarded as the safest area in Quamby, and subject to the most rigorous observations available in Quamby. These two factors ought to have ensured his safety. As a result of the unsafe condition of the unit in which he was placed and the failure of Mr. Barnwell to perform observations, he died.

It is clear on the evidence that if Mr. Barnwell had properly conducted the observations every five minutes, particularly between the hours of 6.00 a.m. and 7.00 a.m. then it is unlikely that Mark Watson would have been able to fashion the noose out of the sheet, place it through the gap between the shelf and the wall and then proceed to jump off the shelf and hang himself. In my view it is inevitable in those circumstances that there be a finding that Mr. Barnwell contributed to the cause of death of Mark Watson.

DANIEL MARK BAKER Mr. Baker was the senior youth worker in charge on that evening, and as I have indicated, failed completely to carry out his supervisory responsibilities. He did nothing to check on the activities of Mr. Barnwell and did nothing to check on the activities of Ms. Dillon. He encouraged Mr. Barnwell to leave his post and did not ensure that if Mr. Barnwell did leave his post he was replaced before doing so and so ensure that there were no gaps in the

observations. He made false entries in the control room log book and generally was in total dereliction of his responsibilities to ensure the safety of Mark Watson and all other persons resident in Quamby on that evening. I am of the view in those circumstances that there must be a finding that Mr. Baker also contributed to the cause of death of Mark Watson.

DIANNE JOY DILLON It was not a responsibility of Ms. Dillon to ensure that observations were carried out by Mr. Barnwell. She had an overall responsibility in relation to residents at Quamby but no specific responsibility in relation to Mr. Watson. In those circumstances I am of the view that it is not appropriate to make a finding that she contributed to the cause of death of Mark Watson.

IAN CRAIG SHERER Mr. Sherer was the reluctant relief of Mr. Barnwell and ought not have been put in the position that he was by Mr.

Baker. The operation of the early on early off regime led inevitably to the problem which occurred that morning.

Mr. Sherer was part of that system. Mr. Sherer attended, reluctantly, upon the duties of carrying out the observations on Mark Watson, but it is clear on the evidence that Mr. Barnwell did not leave the vicinity of the six bed unit until Mr. Sherer arrived. Mr. Sherer commenced his observations almost immediately upon his arrival and it is clear on the evidence that at the time he commenced those observations Mark Watson was already hanging. There is nothing in the conduct of Mr. Sherer that would enable me to make a finding that he contributed to the cause of death of Mark Watson.

CHRISTOPHER JOHN WITHERS Mr. Withers was not responsible for the control of Quamby until 7.00 a.m. He, however, accepted the early departure of Mr. Baker and therefore is responsible in the sense that he was the only person present in a supervisory role between about 6.30 a.m. and 7.00 a.m. It is clear that at that time Mark Watson was probably already hanging. Mr. Withers, once he became involved in the incident, conducted himself commendably and I have already commented upon that. Notwithstanding his involvement in the early on early off regime I do not believe that it is appropriate to make a finding that he contributed to the cause of death of Mark Watson.

MARK GERARD BENNETT Mr. Bennett was also present at the time of the attempts to resuscitate Mark Watson but there is nothing about his involvement in this matter which would allow me to contemplate making him the subject of a finding that he contributed to the cause of death of Mark Watson.

FRANCIS PARATA WOODS Mr. Woods was the acting manager of Quamby at the time of the hanging of Mark Watson. In this role he carries the initial responsibility for that death. I have already commented at length upon Mr. Woods and enumerated some, at least, of the failures and omissions which I believe he was responsible for at the time of the death. I have given careful consideration to whether it would be appropriate to make a finding that he contributed to the cause of death of Mark Watson. It is clear on one view of the evidence that he did contribute to the cause of death as a result of his direct failures to carry out proper searches and to give adequate instructions. However, as I have indicated earlier, his role at Quamby was confused by the overshadowing presence of Richard Young. I am of the view that bearing in mind the particular circumstances of Mr. Woods it would not be appropriate to make a finding that he contributed to the cause of death of Mark Watson. I make this decision only based on the fact of his inexperience and the control over him exercised by Richard Young.

RICHARD GEORGE YOUNG I have already commented upon Mr. Young and my view of his role in the administration of Quamby. As I have indicated, I accept that Mr. Young cannot ultimately be held directly responsible for all the day to day activities of Quamby as they were the responsibility, initially at least, of the acting manager. It is clear, however, that Mr.

Young had an overwhelming influence in the running of Quamby and this influence is particularly evident in the activities of the morning of the 16th of September. I am of the view in all of the circumstances that his role was so significant and his responsibility so great that he must be held to have contributed to the cause of death of Mark Watson.

LYNETTE HILLHORST I am not able to make any finding that Ms. Hillhorst contributed to the cause of death of Mark Watson.

RUSSELL HERTEL Although Mr. Hertel had a significant role in relation to the activities of the 16th of September 1996 and in particular in relation to the return of Mark Watson to Quamby on that date, and it is appropriate that some of his failings on that day be criticised, I do not believe that it is appropriate to make a finding that he contributed to the cause of death of Mark Watson.

I would formally find, pursuant to the provisions of section 24, that the quality of care and the failure of supervision on the part of Mr. Richard George Young, Mr. Daniel Mark Baker and Mr. Ian William Barnwell contributed to the cause of death of Mark Watson.

2. RECOMMENDATIONS (SECTION 58) Section 58 of the Act allows a Coroner to make recommendations to the Attorney-General on any matter connected with an inquest, including matters relating to public health or safety or the administration of justice.

Based upon the evidence put before me during the inquest I would make the following recommendations:

1. I would recommend as a matter of urgency that there be an inquiry into the problems caused by the dynamics of the children resident at Quamby. It is clear from the evidence that if the situation which existed as at September 1996 is to continue, particularly insofar as the mix of children, then there needs to be much more careful selection and training of staff to manage the institution. There would need to be included in this inquiry consideration of whether it is appropriate to continue to contain within the one institution all of the types of people current held at Quamby. It may be undesirable for this situation to continue. The evidence would suggest that such an inquiry ought to be held in public and perhaps desirably might be referred to a standing committee of the Legislative Assembly.

2. I would recommend that urgent consideration be given to the construction in the Territory of a proper facility at which young people involved in the criminal justice system with mental health or behavioural problems are able to be detained under proper medical supervision.

3. I would recommend that there be only one governmental division responsible for all administration of Corrections within the Territory. The further consideration of this recommendation might usefully be part of any inquiry held as I have recommended in recommendation 1. above.

4. I would recommend the role of Director occupied by Mr. Young be changed in such a way as to ensure that it is not occupied by a person who has an active day to day role in the management of Quamby. It must be clear that the manager of Quamby is to manage Quamby and only be overseen in a responsible way by a Director. I support the position described in the submissions filed on behalf of the Department to which I have referred.

5. I would recommend the abolition of the present system of on call managers and would recommend that it be replaced by a system suggested in the Stevenson Report of paying the actual manager a special allowance to be on call at all times. If this recommendation is not acceptable then I would recommend that as a minimum requirement any person acting as the on call manager who is not the actual manager of Quamby must report in all circumstances to the actual manager and to no other person.

6. There needs to be a thorough and urgent review of the policy and procedure manual to provide proper and complete instructions particularly in relation to all elements of care and safety relating to the placement in Quamby of children and young people.

7. I would recommend that there be an immediate change to the policy relating to the availability of keys to workers particularly on the night shift at Quamby. This policy must allow for keys to be either carried on the person of the worker or if that is deemed in the interest of safety and security of the residents not to be appropriate, then to be immediately available to a worker without any delay. This policy must be included and clearly enunciated in the policy and procedure manual.

8. I would recommend that there be a review and change to the policy relating to access to units by individual workers. Commensurate with interests of safety and security of the residents it is essential that a single worker be able to access immediately a unit when there is an emergency situation. Such a policy must be included and clearly enunciated in the policy and procedure manual.

9. I would recommend that there be contained in the policy and procedure manual a direct instruction to require a full and complete inspection and search of any unit in which an incident of self harm has occurred and that there be a full report in substantial detail provided by any workers involved in such an incident. Any report of this nature ought to be kept on the individual's dossier and be available to managers as a matter or urgency.

10. I would recommend that there be a review of the administrative procedures relating to file keeping particularly in relation to individual young people maintained at Quamby so that all information relating to an individual is maintained in the one file. As part of this recommendation I would also recommend that there be clear instructions issued in the policy and procedure manual to require a clear trail to be available in a young person's file to indicate all action that has been taken in relation to the induction, housing and observations of a young person during a stay in Quamby. This file must be available immediately to all staff members and must be kept up-to-date. This file ought also contain a copy of any information obtained about the detainee by the Australian Federal Police during the charging process.

11. I would recommend as part of an overall investigation into the administrative shortcomings at Quamby that careful consideration be given to the role of the control room log book and the special observation book. It is clear that workers must understand the role of those books and the necessity for them to be accurately and honestly completed. This requirement ought also be reflected clearly in the practice and procedure manual. There is also a need to ensure directions within the practice and procedure manual to require shift supervisors and managers to properly supervise and audit both the special observation book and the control room log.

12. I would recommend that there be a formalised direction contained in the policy and procedure manual requiring a formal shift handover. This formal shift handover ought appropriately involve all members of the ending shift and all members of the ongoing shift and that documentary evidence be maintained by the shift supervisor relating to the matters passed on to the oncoming shift.

13. I would recommend the development of a protocol between the Mental Health Crisis Team and the administration of Quamby to ensure that all information obtained by members of the Mental Health Crisis Team concerning the circumstances of a person residing at Quamby who has engaged in conduct that required the attendance of the Mental Health Crisis Team is to be passed on in full to the relevant authorities at Quamby.

14. I would recommend that action be taken, where still relevant, under the provisions of the Public Sector Management Act 1994 to dismiss from the Australian Capital Territory Public Service the following:

1. Richard George Young

2. Daniel Mark Baker

3. Ian William Barnwell

4. Dianne Joy Dillon

5. Peter Michael Mewburn

3. COMMENT Section 56(4) of the Act provides: "A Corner may comment on any matter connected with the death or fire, including public health or safety or the administration of justice." I list hereunder a number of matters which I have considered more appropriately reserved for comment rather than for specific recommendation. A number of the matters, however, while appropriately regarded as comments are significant and ought to be given proper consideration.

4. A substantial body of evidence has been presented to this inquiry concerning staff problems which have been of long standing and which appear to have significantly effected the capacity of Quamby to be efficiently run. For reasons which I have already set out in detail it was not appropriate for me to pursue these problems in any great detail. However, it is clear that there ought to be careful consideration given to the material provided to the inquest relating to this particular area. I have enclosed with a copy of my report to the Attorney-General copies of the material, a list of which is contained in annexure A. I accept that the Stevenson Report has covered some of the matters raised in the evidence before me but it does appear that that Report did not interview all of the persons who indicated to the inquest a willingness to provide information. Regrettably there may be a need for some further investigations to be made or for the material to be dealt with in some other appropriate way so that the matters raised by the various witnesses and workers is appropriate dealt with.

5. There was some evidence given to the inquest about difficulties in obtaining access to appropriate community services for the benefit of Mark Watson. It is clear that young people in a situation similar to Mark Watson represent a substantial challenge to those responsible for their community assistance. It is clear that persons like Mark Watson are substantial consumers of resources both financial and in relation to personnel. It is clear from the evidence that there must be a conscious effort to provide adequate and on occasion more than adequate resources, both economically and in personnel to enable quick and appropriate action to be taken to assist young, vulnerable people. The lack of resources in Quamby which was complained of by a number of witnesses is clear evidence of the need to focus carefully the limited resources available within the community for the use of those most urgently in need of them.

6. Consideration needs to be given to the issue of the debriefing sessions which occur after incidents of this type.

There is a suggestion that during this debriefing session all those involved were able to recount their versions of events and that this recounting caused confusion in the memory of some of those involved in the debriefing session as to what had actually occurred. Debriefing sessions and counselling after such incidents are no doubt essential in circumstances of this type, but I would suggest that they only occur after full and complete statements have been obtained from all relevant witnesses.

SUBMISSIONS Submissions were received from a number of the parties and I am grateful to all for the care and thought that has clearly gone into those very useful submissions. I am particularly grateful for the submissions prepared by Mr.

Archer and Ms. Jones and for their assistance, together with Mr. Buddin, in the conduct of the inquest. I am also grateful for the lengthy and very useful submissions prepared by counsel representing the Australian Capital Territory and the Department of Education and Community Services. A submission was filed on behalf of Mr.

Young by Ms. Tonkin, who represented Mr. Young during the inquest. It is appropriate I believe that I make a specific comment concerning that submission. At the bottom of page 1 in the preamble Ms. Tonkin makes the following comment: "It was apparent from the outset that the inquest into Mark Watson's death was to be a repetition of the inquiry into the Belconnen Remand Centre. It appeared that the outcome of the inquiry was prejudged prior to any of the evidence having been heard". It is not clear from this comment whether Ms. Tonkin is directing her latter comment at Mr. Buddin or myself. If she is referring to Mr. Buddin then her comment is offensive; if she is referring to me then her comment is contemptuous. Tragically it was inevitable that reference be made to the inquiry into the Belconnen Remand Centre as the circumstances of the death of both Shannon Camden and Mark Watson were inquiries which were conducted by myself. It is also inevitable that reference be made to the Belconnen Remand Centre inquiry because many of the problems which arose in that inquiry, particularly concerning administration, were re-emerging in relation to the inquiry into the death of Mark Watson. It was not my intention to engage in a repetition of the inquiry into the Belconnen Remand Centre, but regrettably much of the evidence led in this inquest bore a remarkable similarity to that which had been led in the inquest into the death of Shannon Robert Camden.

In relation to the issue of prejudging, this, of course, is a most offensive and inappropriate comment whether it relates to me or to Mr. Buddin. It is interesting to note that the preamble to this comment made by Ms. Tonkin refers to an application made to the Supreme Court to disqualify me from continuing with the inquest into the death of Mark Watson on the ground of apprehended bias. The basis of this application, which was unsuccessful, was as I understood it that I had been involved in an earlier stage with the Children's Court proceedings that resulted in Mark Watson being returned to Quamby. There was not, as I understand it, any application made on the basis of my having prejudged the inquest into the circumstances of the death of Mark Watson.

I note that Ms. Tonkin in her final sentence of her detailed submissions submits "It is submitted that the learned Coroner will not find that Mr. Young was responsible on a systemic or personal level for the death of Mark Watson". I am not able to accept this submission. As I have indicated in my view Mr. Young was responsible for the system as it operated and contributed to the cause of death of Mark Watson.

The Community Advocate, Ms. McGregor, provided a valuable submission and a number of her recommendations will be accepted. I intend in my report to the Attorney-General to include copies of all the submissions received by me in this matter.

CONCLUSION The evidence put before this inquest revealed a situation in which an environment had developed over a long period of time involving both workers and management in which persons employed to ensure the care and safety of young people detained at Quamby failed in varying degrees in the proper execution of those responsibilities.

The death of Mark Watson has clearly set in train substantial changes to the structure and operation of Quamby and it is hoped that those changes will continue and be reinforced by diligent management to ensure that in the future there can be no compromise in relation to the great responsibilities of those employed at Quamby.

I would wish to end my judgment by thanking, once again, all those whose unstinting efforts have enabled the exposure of the problems about which evidence has been given. Without their efforts, and in particular, the efforts of Mr. Buddin, the then Director of Public Prosecutions, Mr. Ken Archer and Ms. Elizabeth Jones this exposure would not have occurred. I would wish to thank, again, and commend the efforts of my associate Mrs. Neila Schmidt for her efforts and support during the inquest and, more particularly, during the preparation of this judgment. Without her effort, which in my view was above and beyond the call of duty, this project would not have been so swiftly concluded.

DATED THE 28th DAY OF JUNE 1999

MICHAEL A. SOMES, CORONER Attachment "A"

SCHEDULE OF DOCUMENTS FORWARDED TO ATTORNEY-GENERAL Taped Record of Conversation with Christopher John Withers, 5.12.97 (MFI 9) Taped Record of Conversation with Troy James Stratton, 5.12.97 (MFI 10) Taped Record of Conversation with Mark Kesby, 28.11.97 (MFI 11) Taped Record of Conversation with Margaret Anne Ferguson (Richardson), 4.12.97 (MFI 13) Taped Record of Conversation with Aldo Giucci, 27.11.97 (MFI 14)

Taped Record of Conversation with Deborah Murphy, 27.11.97 (MFI 15) Taped Record of Conversation with Richard Colin Beaton, 27.11.97 (MFI 16) Taped Record of Conversation with Michael Jones, 27.11.97 (MFI 17) Taped Record of Conversation with Russell Mackensie Peterson, 22.11.97 (MFI 18) Taped Record of Conversation with Darren James Williams, 22.11.97 (MFI 19) Taped Record of Conversation with Daniel Mark Baker, 5.12.97 (MFI 20) Taped Record of Conversation with Sabine Isabel Kark, 2.8.97 (Exhibit 36) Taped Record of Conversation with Chris Delly, 18.9.97 (Exhibit 37) Taped Record of Conversation with Neil Tootell, 27.8.97 (Exhibit 38) Taped Record of Conversation with April Louise Masters-Smith, 5.8.97 (Exhibit 39) Media documents received by Sgt. Heathcote from receptionist at Quamby (Exhibit 54) Miscellaneous and assorted documents (Exhibit 61) Photocopies of Instruction 131 from Exh. 64 plus copies (Exhibit 66) Taped Record of Conversation with Richard Grahame Reuben, 30.7.97 (Exhibit 67)

Documents regarding Richard Reuben (Exhibit 68) Taped Record of Conversation with Christopher Withers, 9.8.97 (Exhibit 78) Taped Record of Conversation with Ian Barnwell, 2.8.97 (Exhibit 79) Taped Record of Conversation with Daniel Baker, 13.8.97 (Exhibit 80) Taped Record of Conversation with Dianne Dillon, 13.8.97 (Exhibit 81) Taped Record of Conversation with Peter Dugan, 14.8.97 (Exhibit 83) Taped Record of Conversation with Mark Bennett, 15.8.97 (Exhibit 84) Taped Record of Conversation with Ian Sherer, 28.8.97 (Exhibit 88) Statement Ian Barnwell, 17.9.96 (Exhibit 155) Incident Report prepared by Ian Barnwell (Exhibit 156) Minutes of Senior's Meeting 6.1.94 (Exhibit 165) Minute to Manager from Mark Kesby (Exhibit 168) Documents from Ian Barnwell re staffing issues (Exhibit 169) Document from Ian Barnwell entitled "Escapes and Assaults/Staffing Levels/Security (Exhibit 171) Document from Ian Barnwell entitled Quamby Youth Centre (Exhibit 172)

Document from Ian Barnwell entitled Policy in the Youth Sector (Exhibit 173) Managers instructions 10.8.95 Developing and Implementing Case Plans for Residents - produced by Ian Barnwell (Exhibit 174) Copy of minutes of meeting of 5.9.96 from Ian Barnwell (Exhibit 175) Document from Ian Barnwell re concerns and issues - undated (Exhibit 176) Minute 7.9.95 to Manager re escape of Ian Bransby provided by Ian Barnwell (Exhibit 177) Minute from Rhonda Dabin 15.1.96 re Therapeutic Crisis Intervention/Restraint Training provided by Ian Barnwell (Exhibit 178) Rating sheet - job application - Ian Barnwell (Exhibit 179) Minute 5.9.96 provided by Ian Barnwell - ASO 4 interviews and positions (Exhibit 180) Copy of Senior Meeting minutes 19.5.95 provided by Ian Barnwell (Exhibit 181) Copy of Senior Meeting minutes 2.2.95 provided by Ian Barnwell (Exhibit 182) Draft copy only - document provided by Ian Barnwell entitled Consequences for Actions/Misbehaviour (Exhibit 183) Memo to Giucci from Woods 7.7.97 provided by Ian Barnwell (Exhibit 184) Memo to Giucci from Woods 25.6.97 (Exhibit 185)

Quamby Staff Survey (Exhibit 186) Carbon copy of letter to Richard Young from Giucci dated 18.8.97 provided by Ian Barnwell (Exhibit 187) Minute 20.6.97 Giucci to Woods provided by Ian Barnwell (Exhibit 188) Fax to Ms. Christine Healy re major OH&S breaches (Exhibit 189) Fax to Sgt. Heathcote from Concerned public servant (Exhibit 207) Taped Record of Conversation with Graeme Anderson, 6.11.97 (Exhibit 208) Statement of Franc Woods - 12.11.97 (Exhibit 226) Taped Record of Conversation with Peter Mewburn, 6.12.97 (Exhibit 240) Responses to Quamby Staff Survey (Exhibit 256) Taped Record of Conversation with Christopher Withers, 5,12.97 (Exhibit 277) Taped Record of Conversation with Darren James Williams, 22.11.97 (Exhibit 278) Statement Kevin Phillip Shore, 20.10.98 (was not made an exhibit) Documents (in large white envelope addressed to Magistrate Somes) received by Coroner Somes after the conclusion of evidence.