Inquest into the death of SF

STATE CORONER’S COURT OF NEW SOUTH WALES Inquest: Inquest into the death of “SF” Hearing dates: 13-15 January 2025 Date of findings: 8 July 2025 Place of findings: State Coroners Court of New South Wales at Lidcombe Findings of: Magistrate Joan Baptie, Deputy State Coroner of NSW Catchwords: CORONIAL LAW – death in custody – self-inflicted injury – adequacy of CSNSW’s monitoring – availability of hanging points – assessment and determination of application to go on SMAP File number: 2022/00218649 Representation: Counsel Assisting the Coroner: Mr Matthew Robinson instructed by Ms Rebecca Campbell of the NSW Crown Solicitor’s Office Family: Mr Jonathan Martin instructed by Mr Tame Tupou of Pinnacle Lawyers Commissioner of Corrective Services NSW: Ms Claire Dunn instructed by Ms Loren Ovens of the Department of Communities and Justice

Non-publication orders: The Court has made orders for non-publication of certain evidence, pursuant to section 74 of the Coroners Act 2009.

Details of these orders can be found on the Registry file.

The Court has made an order pursuant to section 75 of the Coroners Act 2009 that there be no publication of any matter (including the publication of any photograph or other pictorial representation) that identifies the deceased person or the deceased person’s relatives as that term is defined in section 75(3). Details of these orders can be found on the Registry file.

Findings: The identity of the deceased The person who died was SF.

Date of Death SF died between 2.35pm on 24 July 2022 and 8.34am on 25 July 2022.

Place of Death SF died at the Goulburn Correctional Centre, Goulburn NSW.

Cause of death The cause of SF’s death was due to Hanging.

Manner of Death The manner of SF’s death was a self-inflicted injury with the intention of ending his life.

Recommendations: To the Commissioner Corrective Services NSW

1. That CSNSW provide training to frontline correctional officers in respect of the management of an inmate’s request for protection or alternative cell placement, including in respect of: a. the applicable policies; b. the persons authorised to administer the Assessment Tool – Inmates under Threat; and c. the requirement or expectation that the Assessment Tool – Inmates under Threat be administered as soon as reasonably practicable or, in the event of policy amendment, within the stated period for completion.

2. That CSNSW reviews its policies and consider imposition of a requirement that where it is determined that an inmate: a. may be at risk from others; or b. requires alternative cell placement as a result of a threat to the personal safety of the inmate; or, c. requires alternative cell placement as a result of a request by the inmate due to fears for their personal safety; completion of the Assessment Tool – Inmate under Threat, occur within four hours unless in exceptional circumstances.

Contents The appropriate timeframe for the completion of the Assessment Tool – Inmates under At what time did SAS Duckworth and FCCC Coll finish their shifts on 24 July 2022? .... 21

Section 81(1) of the Coroners Act 2009 (NSW) requires that when an inquest is held, the coroner must record in writing his or her findings as to various aspects of the death. These are the findings of an inquest into the death of SF.

Introduction 1 This inquest concerns the death of Mr “SF”. A non-publication order has been made regarding the name of the deceased Mr SF during these proceedings.

Mr SF will be referred to as “Joel” in these findings.

2 Joel was born on 7 November 2002 in Tonga. He died between 24 – 25 July 2022 at Goulburn Correctional Centre, Goulburn, in the state of New South Wales at the age of 19 years. At the time of his death, Joel was in lawful custody, on remand awaiting the finalisation of criminal charges.

3 Joel died from injuries sustained as a result of an apparent hanging in his cell.

4 The identity, date and place of Joel’s death are not in dispute. Similarly, his cause of death is not in dispute. This inquest has focused on the manner of Joel’s death and the relevant contributing circumstances, including Corrective Services procedures, policies and training relating to persons in custody in

NSW.

5 Joel was the much-loved son of Ms MV and Mr FF. He was the brother to 12 siblings. He was also a grandson, nephew, cousin and uncle to many in his extended family. He was a loyal and supportive friend and hard-working colleague to many.

6 Members of his family have been constant advocates for him and have been unwavering in their determination to ascertain the reasons for his unnecessary death. Various family members and friends have participated and contributed during these proceedings, and I acknowledge the profound loss and anguish felt and experienced by his family and friends.

7 I would like to express my sincere condolences for their loss of this young man who they knew as their loving son, grandson, nephew, cousin and uncle. I hope that Joel’s memory has been honoured by the careful examination of the circumstances surrounding his death and the lessons that have been learned from the circumstances of his passing.

The role of the Coroner and the scope of the inquest 8 A coroner is required to investigate all reportable deaths and to make findings as to the person’s identity; as well as when and how the person died. A coroner is also required to identify the manner and cause of the person’s death. In addition, a coroner may make recommendations, based on the evidence adduced during the inquest, which may improve public health and safety.

9 A person can be detained in lawful custody either as a result of the refusal of bail pending the determination of alleged criminal charges, or as a sentenced prisoner after conviction.

10 In circumstances where Joel’s death occurred whilst he was in lawful custody, an inquest is mandatory pursuant to sections 23 and 27 of the Coroners Act 2009 (“the Act”). Parliament recognised the importance of conducting a mandatory inquest into the death of an inmate who has been deprived of their liberty. A person in custody is necessarily reliant on the State, and the facility in which they are incarcerated, to provide an adequate level of care during their incarceration. A mandatory review of the circumstances of Joel’s death is an important safeguard for persons incarcerated in New South Wales.

11 During these proceedings, a brief of evidence containing statements, interviews, photographs and other documentation, was tendered in court and admitted into evidence. In addition, oral evidence was received from numerous witnesses.

12 All the material placed before the Court has been thoroughly reviewed and considered. I have been greatly assisted by the oral submissions prepared by counsel assisting, Mr Matthew Robinson, Ms Clare Dunn, solicitor advocate on behalf of the Commissioner of Corrective Services NSW, and Mr Jonathan Martin, counsel on behalf of Joel’s family. At times, I have embraced their descriptions in these findings.

13 Non-publication orders have been made in accordance with an application made on behalf of the Commissioner of Corrective Services NSW pertaining to the evidence tendered in the proceedings. As mentioned at the commencement of these findings, there has also been a non-publication order of the names, photographs or any other information that would identify the deceased or any of his relatives as that term is defined in section 75(3) of the Act in connection with these proceedings.

A Brief Overview of Joel’s Life 14 Joel was born in Tonga. He was the twelfth child in a family of thirteen children.

15 On 1 March 2007, Joel and his younger brother travelled to Australia with their mother to visit family, including their grandparents. Some of Joel’s extended family were also residing in Sydney.

16 Joel and his mother and brother were granted permanent residence status in

2013. As soon as he had been granted permanent residence, Joel began travelling to Tonga to see his father and his extended family.

17 Joel completed Year 12 of his schooling in Australia in 2020. He commenced working with his older brothers who trained him in various roles in the construction industry. At the same time, he was providing financial support to his younger brother to complete his schooling and support his younger brother’s partner.

18 Joel commenced a relationship with Ms L. They were together for at least 2 years at the time of his incarceration.

Background 19 On 27 May 2022, Joel was arrested and charged with robbery whilst armed with a dangerous weapon, being a fishing knife. On his arrest, Joel participated in an interview with police and made full admissions to his involvement in the commission of the crime as alleged. He also inculpated his co-accused in the commission of the robbery.

20 Joel was bail refused by police and placed before Mt Druitt Local Court on 27 May 2022. It is unclear whether Joel made an application to be released on bail by the Court, however, it is clear that he was ultimately bail refused by the Court. Joel had not been incarcerated previously.

21 Joel was initially detained at Amber Laurel Correctional Centre. Whilst detained at that facility, Joel completed a form titled “New Inmate Lodgement & Special Instruction Sheet”. The relevant form noted that Joel “appears calm rational and settled at time of lodgement interview. Nil issues at this time.” 22 On 28 May 2022, Joel was moved to the Metropolitan Remand and Reception Centre (“MRRC”), in Sydney.

23 At the MRRC, the Intake Screening Questionnaire, noted that Joel had presented calmly, was well engaged, co-operative and answered all the questions in a polite manner. It was recorded that he denied any thoughts of

self-harm, or suicidal ideation and “guaranteed his own safety.” He denied any physical or mental health issues and said he was feeling “not too bad”.

24 The Intake Screening Questionnaire noted that although Joel had “no thoughts of self-harm or suicidal ideation”, he did request to speak with a psychologist to help him with coping mechanisms for anxiety related to being in goal for the first time.

25 Joel was reviewed daily from 28 May to 8 June 2022, by a registered nurse employed by the Justice Health and Forensic Mental Health Network, for routine COVID-19 checks.

26 On 31 May 2022, Joel’s request to speak with a psychologist was triaged by Ms Bethany Holloway and placed on a waiting list for “Psych 2 Sub-acute Mental Health Impairment on the basis of information available, to be seen in order of priority.” The Practice Guidelines for Subacute Mental Health Impairment, require a person who has been triaged to the ‘Psych 2 Service Line’ is interviewed and/or assessed within twelve weeks of the initial application.

27 On 20 June 2022, Joel was moved to Goulburn Correctional Centre.

28 Joel was placed in a “two out” cell with another inmate.

29 On 21 June 2022, Ms Amy Cowan, a psychologist attempted to speak with Joel.

He declined the appointment.

30 On 23 July 2022, Joel had a conversation with his girlfriend, Ms L, via AVL.

31 On 24 July 2022, Joel provided a note to one of the Correctional Officers, requesting that he be moved to another cell. Later, that day, Joel was moved to a “one out” cell on the ground floor of the wing. He was locked in his cell at 2.35pm and was not seen again until 8.30 am the following morning. That morning, he was discovered hanging from the inner grill of the cell door with a bed sheet tied around his neck and was non responsive. He was subsequently declared deceased.

List of issues considered during the inquest 32 The following list of issues was prepared before the proceedings commenced, circulated to the interested parties, and was considered and provided focus during the inquest.

1. The statutory findings required under section 81 of the Coroners Act

2009 (NSW).

2. Whether Joel’s request to see a psychologist was adequately addressed by Corrective Services NSW (“CSNSW”).

3. The reasonableness of CSNSW, having been informed by Joel of his wish to go on Special Management Area Placement, (“SMAP”), leaving Joel in a “one out” cell on the afternoon/evening of 24 July 2022 rather than his application being assessed and determined promptly.

4. The adequacy of CSNSW’s monitoring of Joel after he was placed in Cell 4, Unit 4.

5. The availability of hanging points in Cell 4, Unit 4.

Joel’s mental health and assessment in custody 33 Prior to his incarceration on 27 May 2022, Joel had no known history of mental health concerns or issues.

34 At his reception to the Amber Laurel Correctional Centre later on 27 May 2022, Joel was assessed as appearing to be “calm rational and settled at time of lodgement interview, Nil issue at this time.” 35 On 28 May 2022, Joel was moved to the Metropolitan Remand and Reception Centre (“MRRC”) and an Intake Screening Questionnaire was completed. Joel was described as presenting “calmly, engaged well, was cooperative and answered all questions in a polite manner.” He denied thoughts of self-harm, or suicidal ideation and indicated that he “guaranteed his own safety.” He denied any physical or mental health issues and said he was feeling “not too bad.” Joel is recorded as requesting to speak with a psychologist to help provide him with coping mechanisms for anxiety related to being in gaol for the first time.

36 Similarly, a Health Problem Notification Form (“HPNF”) dated 28 May 2022, recorded that Joel had no thoughts of self-harm, and that he denied any medical/mental health issues.

37 On the same day, a Reception Screening Assessment was conducted by a registered nurse (“RN”) Ms Ka Ian. Joel confirmed to RN Ian that he had never been told, or thought he had, depression, anxiety, or any other mental health problem. He denied having ever received treatment for any mental health issues. He advised RN Ian that he believed he would be able to cope in gaol.

38 RN Ian noted that she did not consider a mental health referral was required and accordingly, she did not complete a mental health referral. Similarly, she did not place Joel on a Risk Intervention Team (“RIT”) management plan.

39 On 31 May 2022, Joel’s request to speak with a psychologist was triaged by Ms Bethany Holloway, who noted: “Referral received, not yet seen, triaged and placed on waiting list for Psych 2 Sub-acute Mental health impairment on the basis of information available, to be seen in order of priority.” 40 A Psych 2 notation indicates a sub-acute psychology service. It is not intended to provide a service for persons thought to be at risk of self-harm or suicide.

On the available evidence, this decision would appear to have been appropriate.

41 The Practice Guidelines for Subacute Mental Health Impairment at 1.11, provide that a person triaged to the Psych 2 Service Line should be followed up within twelve weeks. The records confirm that the “follow up” was initiated on 21 June 2022.

42 Joel was transferred to Goulburn Correctional Centre on 20 June 2022. On his admission to Goulburn gaol, the Reception Transfer Checklist was completed.

The checklist noted that there were: a. No safety concerns in custody; b. No immediate medical requirements; c. No thoughts of self-harm; d. No thoughts of suicide; e. No violent thoughts or feelings; and f. No need for protection.

43 On 21 June 2022, an entry is recorded in the Offender Integrated Management System (“OIMS”), Correctional Officer (“CO”) Joshua Quinlan noted, “inmate has been interviewed again as per reception protocol and has stated nil issues, nil association issues and nil problems with going out to the remand yard.” 44 The Governor of Goulburn Correctional Centre, Ms Leah Nicholson confirmed in her written statement that: “Joel was not deemed to be at risk of suicide so he was not placed under the management of a risk intervention team (RIT). Further he didn’t have an

active health problem notification form identifying that he required two-out cell placement. Given this Joel was not placed into an observation cell.

There were no requirements for monitoring or observations of Joel beyond the usual centre practices.” 45 On 21 June 2022, Ms Amy Cowan, psychologist, attempted to speak with Joel in terms of following up with the Psych 2 request from 31 May 2022.

46 Ms Cowan provided a statement for this inquest dated 17 November 2023. Due to Joel’s recent arrival at Goulburn gaol and the fact that he had not been seen previously by a psychologist at the MRRC, it was decided that Ms Cowan would interview Joel in person to assess his mental health needs.

47 Goulburn Correctional Centre is a maximum security facility. The psychological staff offices are located away from the accommodation wings, and it is usual that the psychologists provide correctional officers with a daily list of inmates that they wish to review. Correctional officers then arrange for the safe escort of the inmate to the psychologist’s office. Ms Cowan made such a request to officers on 21 June 2022.

48 Ms Cowan stated that she was “Advised by custodial officer that offender refused to attend.” There is no evidence available to determine the nature or the details of the conversation between the officer and Joel.

49 Joel was entitled to decline to attend the appointment with the psychologist.

It was not an infraction and would not result in any form of punishment.

50 Ms Cowan recalled that she was aware that Joel had been screened on 20 June 2022 on his arrival at Goulburn Correctional Centre and that no suicide risk was identified at that time. It was her view that there was no reason to elevate Joel’s priority for review to the “Psych 1 line” notation, nor any urgency to follow up with him at the yard fence. Ms Cowan indicated that the ‘yard fence’ is the “only other option” available to her to review an inmate if they decline to attend the psychologist’s office. She opined that the ‘yard fence’ is a less desirable option as it lacked an opportunity for a confidential discussion with the inmate.

51 Ms Cowan decided to leave Joel on the Psych 2 service line. This meant that his referral would not be closed, and a follow-up should have occurred within twelve weeks. Available records do not disclose any further attempt being made prior to his death five weeks later. The absence of any further follow-up within that time period was not unreasonable.

52 Whilst this scenario was not unreasonable, it presents as a missed opportunity to identify how a potentially vulnerable young man was coping in

a custodial setting. There is no independent evidence to suggest that Joel was not coping during his time at the MRRC, nor during some of his stay at Goulburn.

53 By late July 2022, there was evidence that was capable of inferring that Joel was experiencing some difficulties with his custodial setting.

54 This evidence includes: i. Comments made to his girlfriend during an AVL call on 23 July 2022; ii. Evidence provided to police from his cell mate after his death; and iii. Other Pacific Islander inmates encouraging and supporting him to remain positive.

55 On 23 July 2022, Joel and his girlfriend spoke for a period of time via an AVL call. A transcript of the call forms part of the brief of evidence that was tendered. During the call, Joel stated on two occasions that he was depressed and commented “I can’t without you” and that he had “too much on my mind.” Ms L reassured Joel that he would be fine, and Joel responded, “I know, what’s what the boys keep telling me”. Joel stated that he would read the bible when he was sad. He later confirmed that he had been crying, however, he was hoping to be released on bail soon.

56 Joel’s cell mate, Mr BW, participated in an interview with investigating police after Joel’s death. In his interview with police, Mr BW stated that Joel was “real depressed” and “heaps depressed”. He continued, stating that Joel thought about “the outside heaps” and “barely spoke”. Mr BW indicated that Joel was quiet, and would sit and look at the wall, and would only talk about his girlfriend. Mr BW told police that he had no knowledge of Joel being threatened by anyone in custody.

57 Joel was represented by , solicitor. was employed by the Legal Aid Commission of NSW and was an experienced criminal lawyer.

provided a statement in these proceedings which was included in the brief of evidence that was tendered. recollection was assisted by reference to a contemporaneous file note.

58 The file note included a notation “send client BOE next week”.

confirmed in her statement that “BOE” was a reference to the Brief of Evidence, and that she was “going on leave, will send BOE before leave”.

stated that she was confident that Joel either requested access to

the brief of evidence or answered in the affirmative when she asked him whether he would like to receive a copy of the brief of evidence.

59 The Legal Aid Commission forwarded a copy of the brief of evidence to Joel on 20 July 2022.

60 The brief of evidence contained the transcript of an Electronically Recorded Interview with a Suspected Person (“ERISP”) between the investigating police and Joel. In the ERISP, Joel made admissions to his involvement in the alleged robbery, as well as implicating other co-accused.

Events on 24 July 2022 61 Joel had been housed in Cell 28 located in Unit 4 at the Goulburn Correctional Centre since 7 July 2022. He shared this cell with Mr BW. This was a maximumsecurity remand wing.

62 On 24 July 2022 at 2.20pm, the prison officers were delivering dinner to the inmates in Unit 4.

63 First Class Correctional Officer (“FCCO”) Farrell prepared an incident report, as well as a statement about his recollection of what transpired between him and Joel at 2.20pm on 24 July 2022. He also gave oral evidence during the inquest.

64 In FCCO Farrell’s incident report, he stated that he attended cell 28 which housed Joel and his cell mate. At that time, FCCO Farrell indicated that Joel came out of the cell and handed him a note. In his statement prepared for these proceedings, FCCO Farrell noted that “While feeding the locked in inmates on opening cell door, Joel seemed worried and anxious, and dropped the note where the meals were on the floor”. In oral evidence, FCCO Farrell agreed there were inconsistencies with these two versions, and confirmed that Joel had dropped the note at FCCO Farrell’s feet, near the tray of meals.

65 FCCO Farrell picked the note up from the floor. The note stated, “I’m scared for my safety having my brief hidden I don’t want anyone to know I’m a dog can you remove me please, without my celly knowing?” FCCO Farrell could not recall when he read the note.

66 FCCO Farrell recalled speaking with Corrections Officer Quinlan and showing him the note. They both approached Joel in his cell and asked that he accompany them, without further explanation. Joel was escorted to the wing office where both officers spoke to Joel about his note and the associated concerns.

67 FCCO Farrell cannot recall the details of the conversation, however, he confirmed that Joel was concerned that other inmates may become aware that he had provided inculpatory evidence regarding his co-offenders to the police during his ERISP, which was contained in the brief of evidence that was tendered. In evidence, FCCO Farrell indicated that the “main concern was about the cellmate.” 68 FCCO Farrell indicated that he was focused on moving Joel to a one-out cell, being cell 4. He said that he was not focused on dealing with Joel’s application to be transferred to a ‘special management area placement’ (“SMAP”) or a protection wing, as that decision would normally be undertaken by a more senior officer, such as an accommodation officer. He commented that Correctional Officer Quinlan was the accommodation officer on that occasion.

69 FCCO Farrell confirmed that Joel was escorted back to cell 28 to collect his belongings and then escorted to cell 4. He had no recollection of speaking to Joel once he was relocated to cell 4.

70 Correctional Officer (“CO”) Quinlan provided two incident reports, as well as giving oral evidence. CO Quinlan described his role on 24 July 2022 as the ‘methadone officer’. CO Quinlan stated that due to staff shortages, there was no accommodation officer on duty that day.

71 CO Quinlan confirmed that Joel had told him and FCCO Farrell that he was “scared the yard would find out from his brief and wished to go to a SMAP wing”. CO Quinlan and FCCO Farrell told Joel that he could collect his belongings and would be housed in a cell on “the bottom landing for the night and we can get you moved in the morning”.

72 Both CO Quinlan and FCCO Farrell confirmed that they each spoke with Joel to enquire whether he had any other issues and whether he was okay.

CO Quinlan stated in his oral evidence that “Officer Farrell asked all the appropriate questions to make sure he was all good. From my point of view he seemed fine just, you know, he was – glad, I suppose, to be out of the cell, so yeah, on his own, and then we were going to organise the paperwork and everything else the next day I believe.” 73 CO Quinlan could not specifically recall contacting FCCO Anne Coll but accepted that it sounded “most accurate” that he had contacted her. He stated that the reason Joel’s circumstances would have been escalated to FCCO Coll was because “she was a senior of one and four, so it’s protocol even though I was potentially the only person in the wing that day and we’d moved him. We obviously have to let someone above you know that a move has been

done so all the relevant paperwork in OIMS (Offender Integrated Management System) and all the, I suppose, boxes are ticked to say that that move has happened, so.” 74 FCCO Anne Coll was the Acting Supervisor of Units 1 and 4 on 24 July 2022.

FCCO Coll prepared an Incident Report and a statement in these proceedings.

FCCO Coll gave oral evidence during the inquest on two occasions.

75 FCCO Coll returned to Unit 4 when she was contacted regarding Joel and spoke with FCCO Farrell and CO Quinlan. FCCO Coll indicated that she was informed of the circumstances which had necessitated the decision to move Joel and agreed with that decision.

76 FCCO Coll stated that she spoke with Joel once he had been relocated to Cell 4. FCCO Coll recalled asking Joel whether he wanted to sign onto SMAP, and that he had indicated that he did. She also recalled asking him if he felt that he was now safe and if he had any mental health concerns. FCCO Coll confirmed that Joel reassured her that he was fine.

77 FCCO Coll stated that she then secured Joel in Cell 4 and returned to her office and obtained an inmate request form and returned to Joel’s cell. FCCO Coll indicated to Joel that he needed to complete the form as a written application to commence his request to be transferred to SMAP.

78 FCCO Coll then spoke with Senior Assistant Superintendent James Duckworth, informing him that she had provided Joel with a request form.

FCCO Coll was satisfied that she had handed over the ongoing responsibility for Joel’s cell transfer to Senior Assistant Superintendent (“SAS”) Duckworth.

SMAP and the appropriate application 79 FCCO Coll gave oral evidence that she asked Joel “if he had any other fears for his safety, any other concerns. I then asked him if he would like to sign on to protection, which is a SMAP placement.” 80 It became apparent during the inquest that there was some confusion associated with the definition of a Special Management Area Placement (“SMAP”) and placement in ‘Protection’.

81 Mr Malcolm Brown, General Manager Statewide Operations, Security and Custody explained that a protective custody order can be given by the Governor of the gaol or the Commissioner of Corrective Services. These orders can be appealed by an inmate through the Serious Offenders Review Council (“SORC”). Alternatively, an inmate can request to be placed in protective custody and such an order does not attract the SORC appellate process.

82 Mr Brown further explained that a SMAP order: “is about providing a cohort of people that have similar vulnerabilities and I think it’s in the regulation under 33(3)(b) around a similar cohort being housed together. So the assessment tool is designed to work out whether or not the inmate is required to be placed in a same cohort, special management area placement, or whether they actually then need to go to the additional level of a protective custody order and I think there’s been a bit of confusion.” 83 Mr Brown agreed that the SMAP policy does not require an inmate to complete a written application.

84 Mr Brown explained that: “Placing an inmate onto non-association (ie SMAP) restricts their level of access to programs, education, work opportunities, it houses them in isolation from others, there’s affects which is quite clearly stated through the Act and through our policy around the effects of separation and isolation, so SMAP is about ensuring that we can have a cohort of inmate that has access to programs, work, education and those types of opportunities depending on their risk.” The correct form and is it required to be completed by an inmate?

85 FCCO Coll provided Joel with an “Inmate Request Form”. In her oral evidence, FCCO Coll agreed that there was another form, referred to as an “Inmate Application Form”. She agreed that the “inmate application form" was the appropriate form, rather than the “inmate request form.” 86 The fact that FCCO Coll provided Joel with the incorrect form, did not materially affect the outcome of Joel’s verbal request.

87 After FCCO Coll had advised SAS Duckworth of Joel’s request, it does not appear that she provided him with the completed form.

88 SAS Duckworth gave oral evidence that it was his understanding that it was a “product of policy” that the inmate was required to complete the “inmate application form” to initiate an application to be moved to SMAP or protection.

89 It became clear during these proceedings that a practice had developed at Goulburn Correctional Centre whereby inmates seeking to be moved and placed in SMAP were required to complete an Inmate Application Form, despite there being no specific policy requirement for this form to be completed after a verbal application had been received from an inmate. The

Inmate Application Form was developed to track an inmate’s application from the time of the initial request through to the outcome of the particular application.

90 The Inmate Application Form is not a form specific to a request for transfer, nor a prerequisite, to be moved to SMAP.

91 Mr Brown, General Manager, State-Wide Operations, stated in his statement dated 12 December 2024, that “Although not provided for in this policy, if an inmate indicates verbally to CSNSW custodial staff that they fear for their safety, it is common practice for the CSNSW Authorised Officer to request the inmate to write and detail their concerns on an Inmate Application Form for record keeping purposes.” 92 Importantly, the SMAP policy specifically caters to inmates who are illiterate or who have English as their second language by not requiring the inmate to complete a written form to activate a request to be reassigned to a SMAP designation.

93 SAS Duckworth confirmed that he had told FCCO Coll that she should provide Joel with a copy of an application form and Joel “can fill that out overnight and we’ll see him in the morning.” SAS Duckworth confirmed that it was his expectation that the Inmate Application Form would be the type of form provided by FCCO Coll.

94 SAS Duckworth confirmed that after the Inmate Application Form was completed, he would administer the “Assessment Tool: Inmates under Threat,” as “a functional manager in charge of the accommodation areas.” 95 SAS Duckworth further indicated that after the “Assessment Tool: Inmates under Threat” had been administered, a form titled the “Special Management Area Placement” form (SMAP form) would be completed by the Functional Manager/Authorised Officer.

Who is authorised to administer the “Assessment Tool: Inmates under Threat”?

96 The Custodial Operations Policy and Procedure (“COPP”) 3.3, relates to the Special Management Area Placement. The summary of that policy states: “A Special Management Area is a part of a Correctional Centre approved by the [Assistant] Commissioner, Custodial Corrections (ACCC) to house inmates who would be at risk if not separated from other inmates.

A Functional Manager (FM) has the authority to place an inmate in a Special Management Area, or cancel such a placement.” 97 The policy further provides that: “The assessment and decision to place the inmate in a Special Management Area are made during the reception process or following receipt of a written application for protection from the inmate, or when staff become aware of a threat to the inmate.” 98 The COPP refers to the Procedure to be adopted as follows:

1. An Authorised officer is to complete the annexure Assessment tool: Inmates under threat, to assist in a determination of the inmate’s management.

Place a copy on the inmate’s file.

2. If the Assessment tool: Inmates under threat, indicates that Special Management Area Placement is the best management option, complete the annexure Special Management Area Placement and include the following details:

• the name and Master Index Number (MIN) of the inmate to be separated,

• the reason for the SMAP,

• when the SMAP would be reviewed (this may vary from inmate to inmate, but must occur at least once per 12 months),

• the location where the inmate will be housed.

Forward the application to the Functional Manager (FM) for endorsement.

This procedure is also directed to an Authorised Officer.

99 The policy defines an Authorised Officer as: “The officer authorised by the Governor to perform the functions prescribed as part of the Custodial Operations Policy and Procedures.” 100 Governor Nicholson confirmed that any Correctional Officer at Goulburn was regarded as an “Authorised Officer.” Governor Nicholson was asked: “Q. Is this right, FCCO Farrell, CO Quinlan, FCCO Coll and SAS Duckworth each could have, if they had determined to, each could have completed the Assessment tool – Inmates under Threat?

A. That’s correct”.

101 CO Quinlan and FCCO Farrell implied that they were not responsible for preparing or completing the SMAP application with Joel and that the paperwork would be completed by other officers.

102 FCCO Coll gave the following oral evidence: Q. “Could you have just commenced that process without a written application by Joel?

A. That I’m not sure of.

Q. Is that an assessment tool that you administer or is that an assessment tool administered ordinarily by more senior officers?

A. I believe it’s done by an FM. That’s part of the SMAP process.

Q. That is it’s not ordinarily done by a First Class Correctional Officer even one performing a supervisory role; is that right?

A. No” 103 SAS Duckworth gave the following oral evidence: Q. “Was it your expectation that after the inmate application form was completed, the Assessment tool – Inmates under threat would be used?

A. Yes.

104 SAS Duckworth was then asked: Q. “Who is capable or able to administer that assessment tool?

A. I’d normally do that myself, as a functional manager in charge of the accommodation areas.

Q. It is not, for example, an assessment tool, is this right which you would expect a first class correctional officer to complete?

A. Not usually a first class correctional officer. Senior correctional officers can fill them out. Not all of them can or will, or have that experience with it.

So if they don’t have experience with it, I’ll do it myself or ask if they want to learn and show them how to fill it out.

Q. Did you expect that First Class Correctional Officer Coll would complete this form?

A. No.

Q And you didn’t direct First Class Correctional Officer Coll to complete this form?

A. No.

Q. The relevant direction you provided was to provide Joel with an inmate application form and that that form would then initiate the appropriate protocol the following morning, is that right?

A. Yes” 105 As it transpired during the inquest, the evidence of FCCO Farrell, CO Quinlan, FCCO Coll and SAS Duckworth was something of a charade regarding their knowledge of which type of correctional officer was authorised to complete the Assessment Tool – Inmates under Threat. The evidence of Governor Nicholson exposed the charade and confirmed that an industrial demarcation dispute had developed over time.

106 Governor Nicholson commenced in her role after Joel’s death and stated: “Yes, however and I know at Goulburn it became quite contentious in relation to whose responsibility it was. As a result of a review called benchmarking, within Corrective Services, we lost a rank in the middle and it was what was pushed up and what was pushed down, so our current practice is still that the FM, functional manager, is the one that completes it and authorises it. It’s a work in progress in trying to get the staff to complete these tasks and that’s an organisation issue not just relevant to Goulburn.” 107 Both SAS Duckworth and FCCC Coll were recalled to give evidence in light of Governor Nicholson’s evidence. Both conceded that they were aware of the direction from the Community and Public Sector Union representing Corrections Officers, that non-commissioned officers should decline to accept responsibility for completing the Assessment Tool – Inmates under Threat.

108 FCCO Coll conceded that the union direction had affected the approach she had adopted on 24 July 2022, regarding Joel’s application process. She further conceded that it was her choice to follow the union’s direction.

109 FCCO Coll confirmed that SAS Duckworth did not ask her to complete the Assessment Tool – Inmates under Threat, nor did she indicate to him that she did not consider it her responsibility given the union direction.

The appropriate timeframe for the completion of the Assessment Tool – Inmates under Threat and transfer to

SMAP 110 SAS Duckworth confirmed that he received notification of Joel’s concerns at approximately 2.45pm, one and quarter hours prior to when he finished his shift at 4pm.

111 SAS Duckworth acknowledged that that would be sufficient time for him to complete the Assessment Tool – Inmates under Threat and the SMAP application form if he was “concentrating on that alone, yes”.

112 SAS Duckworth was asked whether there was any reason that the “Assessment Tool -Inmates under Threat” was not completed on 24 July 2022.

SAS Duckworth responded that: “The inmate was removed from the threat, physically removed. And the time on the day, and that, and the time it would’ve taken to do this, I’ve thought that can be done in the morning, the inmate’s removed from the threat that we are aware of and I emailed Functional Manager – Accommodation, that he to deal with that in the morning. That he’s had to wait for Joel to write the application out, get that and then go from there.” 113 SAS Duckworth also commented that there were staff shortages on 24 July 2022, due to staff members contracting COVID 19, and this may have added to his competing priorities.

114 In any event, SAS Duckworth confirmed that he made the decision to refer Joel’s application to SAS Islip for completion the following morning, 25 July 2022.

115 SAS Duckworth indicated that there is no time frame for the assessment to be completed according to the COPP policy. He confirmed that where there was a threat to an inmate, the assessment should be undertaken as soon as possible.

116 SAS Duckworth acknowledged that approximately 18 hours elapsed from the time that Joel was moved to Cell 4 and the detection of his death. He was asked whether he perceived that this lapse of time was acceptable. SAS Duckworth responded: “Yes. He was – like, I could’ve done the assessment, could’ve done that and he would’ve still been in the same cell. It wasn’t – I can’t remember whether we – it depends whether they’ve got vacancies in the protection

area. I didn’t check that. So more than likely he would’ve been in the same cell that afternoon, that night.” Q. That is to say, even if you had on the afternoon of 24 July determined to complete the assessment tool, thereafter completed the application form and determined he was suitable for SMAP, he likely would’ve remained in Cell 4, Unit 4, is that right?

A. That’s correct.

Q. Why is that?

A. Cause we’d removed him from the threat, which at the time the threat was fearing safety from his cellmate. So he was removed from that situation and in the cell by himself.

Q. But why, once his application had been assessed, and presumably approved, why wouldn’t he have been moved that evening or that afternoon to the SMAP wing?

A. That’s not our normal procedures, unless there’s a further threat. There’s no threat from anyone else in that cell, so he was safe. As that’s not normal procedures to move after lock-in.” 117 SAS Duckworth confirmed that he was unaware that Joel had not been assessed by a prison psychologist during his period of incarceration.

118 The COPP contemplates a situation where the Assessment Tool – Inmates under Threat can be completed by an Authorised Officer, being any correctional officer. The COPP directs that a completed assessment and SMAP application are then provided to a functional manager for approval.

119 SAS Duckworth confirmed that there were occasions when he would complete the assessment tool and then approve his own recommendations regarding the application. He stated that this was likely to occur during a weekend as “our roles and responsibilities as an FMPD is huge, so if I had have done it that day I would’ve assessed and then I probably would’ve approved it.” He agreed that this was an unsatisfactory process.

120 Governor Nicholson gave oral evidence that it was her understanding that if one functional manager prepared the assessment as the assessing officer, they would provide that application to another functional manager for approval. Governor Nicholson confirmed that if there was a practice whereby a functional officer was both preparing and approving the one application, that this would be troubling.

121 Governor Nicholson agreed that it was possible for the assessment tool and associated paperwork to be completed within “an hour, an hour and a half,” if there were no other competing tasks for the officers to deal with in addition to the application.

122 Governor Nicholson agreed that it was possible for one of the correctional officers to have completed the assessment tool and the SMAP annexure and provided that information to SAS Duckworth prior to 4pm on 24 July 2022. She further agreed that if that had occurred, it was possible that Joel could have been moved to the SMAP wing if there was accommodation available in the SMAP wing.

123 Governor Nicholson confirmed that there was no functional officer rostered on from 4pm on 24 July 2022.

124 Governor Nicholson noted that some inmates would not be moved immediately “to ensure that the inmate, particularly if they’ve been placed in a two-out cell, is suitable for placement in that cell both for their own safety and the safety of the other inmate, so again both inmates need to be assessed and that might not – the staff completing the assessment may not have the local knowledge that the regular wing accommodation staff would have.” 125 Governor Nicholson agreed that hypothetically, if there was a one-out cell available in the SMAP unit on the afternoon of 24 July 2022, and Joel’s application for SMAP had been assessed and approved, he could have been moved to a one-out SMAP cell on 24 July 2022.

Staff shortages, lock downs, observations and meal deliveries 126 On 24 July 2022, the inmates in Wings 3 and 4 were the subject of ‘lock in’ due to a staff shortage. Ordinarily, inmates are ‘locked in’ for the night at 4pm.

127 On a usual day, inmates were provided with their breakfast at 7.30am, their lunch at 11.30am and their dinner somewhere between 2 – 2.20pm. The effect of this timetable is that inmates are not provided with any food for a period of 17 hours on a daily basis. This practice appears to be statewide.

128 The food is served both hot and cold, depending on the nature of the meal.

129 The food is labelled with hygiene warnings, including that the food is required to be consumed within 20 minutes of delivery. Governor Nicholson confirmed that it is not unusual that inmates elect not to consume their meals immediately.

130 She further confirmed that the reason for not serving the dinner meal later included the consideration that: “In a maximum security centre it’s two staff minimum to actually open an inmate’s cell after hours. We have had officers attacked. We have had other inmates attacked by their cellmates. There’s multiple issues that can transpire, so it’s for the safety of the inmate and the safety of the staff.” 131 On 24 July 2022, Joel was served his dinner at 2.20pm. No observations were conducted by Correctional Officers regarding Joel for 18 hours.

132 Governor Nicholson conceded that it would be “optimum” if observations of inmates could be conducted on a regular basis after 4pm, however, she does not have the funding to undertake such observations.

At what time did SAS Duckworth and FCCC Coll finish their shifts on 24 July 2022?

133 The evidence discloses that in two of the four wings at Goulburn Correctional Centre the inmates were ‘locked in’ from around 2.30pm. One of those two wings that were ‘locked in’ housed Joel.

134 During the inquest, further enquiries were made by CSNSW regarding the time that both SAS Duckworth and FCCC Coll finished their shifts.

135 Governor Nicholson stated that there was not “a definitive time but I do know that they would’ve finished prior to 4 o’clock. They usually muster and the staff usually parade in the gate at around quarter to 4 and once everything is accounted for, keys, staff, inmates accounted for, then they’ll be let go for the day.” Governor Nicholson opined that they wouldn’t have worked after 4pm as there was “no overtime on that day for any of the staff.” 136 At Goulburn gaol, Corrections Officers were required to provide biological data, for the purposes of signing in and signing out of their shift times.

137 Governor Nicholson stated that the “bio” system had not been working since 2021 and eventually became operational again in August 2024, a month after she commenced in her role as Governor. Effectively, there were no recorded entries confirming the times worked by Correctional Officers for a period of three years. Governor Nicholson indicated that “there is video, CCTV footage, of the staff leaving and entering but I haven’t – because I haven’t been at the centre I haven’t been able to review the footage.” 138 Governor Nicholson was asked:

“Q. Is there another means by which sign in and sign out can occur if the bio system is down?

A. It would be a book.

Q. But that was not used for staff for about three years?

A. No.

Q. Do you have an understanding as to why for three years that system was permitted to remain non-operational?

A. I do not.” 139 Interestingly, the ‘bio’ system used by visitors to the gaol remained operational throughout this period of time.

140 The evidence indicates that there should have been sufficient time for an authorised officer to receive Joel’s request for SMAP placement and to have processed his application prior to the day staff ‘clocking off’ sometime between 3.45 and 4pm.

Cause of Death 141 At 8.34am on 25 July 2022, SAS Islip attended Joel’s cell and found him hanging, suspended by a bed sheet around his neck. The bed sheet had been looped around the bars on the interior cell door.

142 On 1 August 2022, Dr Elsie Burger, Senior Staff Specialist Forensic Pathologist, performed a coronial post-mortem on Joel. Dr Burger concluded that the direct cause of Joel’s death to be “Hanging”.

143 Detective Senior Constable (“DSC”) Kelli Moller and other investigating police located a seven-page letter in Joel’s cell, which appeared to be written in his handwriting.

144 According to the evidence, Joel was not seen by any correctional officers or other inmates from 2.35 pm and 8.34 am the following day, a period of 17 hours and 59 minutes.

145 The evidence, however, does not permit a conclusion as to when Joel died during that almost 18 hour period. It does appear that he had been deceased for some hours, given his extremities and his torso were cold to the touch, blood had pooled in his hands bilaterally, his pupils were fixed and dilated, and he had rigidity and stiffness throughout his body.

146 In relation to the manner of Joel’s death, in my view, it is sufficient and appropriate in the discharge of my statutory function pursuant to the Act to find that Joel’s death was as a result of a self-inflicted injury with the intention of ending his life. For this finding to be made the evidence must be extremely clear and cogent in relation to intention. The proper evidentiary standard to be applied to a coronial finding of intentional taking of one’s own life is the Briginshaw standard (Briginshaw v Briginshaw 60 GLR 336). Although Joel’s actions were not witnessed, the evidence establishes, on balance, how he caused his injuries which was hanging using a bed sheet looped around the bars on the interior of his cell door.

Ligature Hanging Points 147 DSC Kelli Moller prepared a statement for these proceedings, dated 26 July

2022. DSC Moller noted that: “I saw that the front heavy/solid door of the cell was open as well as the internal door. I could see a small piece of green sheet attached [to] the internal door at the top left-hand side of the door. The internal door was heavy metal bars that had a sheet of Perspex screwed to it, but at the top there was a gap of approximately 10cm. This is where I could see the piece of green sheet wrapped through it.” 148 Governor Nicholson confirmed in her oral evidence that Cell 4 is no longer an operational cell at Goulburn Correctional Centre. The cell does not appear to have been decommissioned, but rather was part of an adjustment program where the gaol was reduced in capacity and two of the wings were closed and the current two wings had their capacity reduced on 15 February 2024.

149 Governor Nicholson stated that the type of internal cell door in Cell 4 is not in use elsewhere at Goulburn Correctional Centre.

150 In July 2022, there were a total of six camera cells. Governor Nicholson indicated that there are currently “two that are currently operational and they are both in 2 Wing. The other two were in 1 Wing, which is now closed, and there is an observation cell which is camera-ed but I don’t deem it to be a safe cell in the clinic for medical observations, only medical observations, because it is not deemed a safe cell.” Considerations 151 Joel was 19 years of age and had never been held in a custodial setting before his incarceration on remand in 2022.

152 Due to the charges that he was facing, Joel was held in maximum security facilities during the entirety of the time he was held in custody.

153 The evidence confirms that Joel was lawfully in custody at the time of his death.

154 Prior to his incarceration, Joel had not been assessed or treated for any mental health issues. During his incarceration, there was no evidence to suggest that he had complained of any mental health concerns. Towards the end of his period of incarceration there was anecdotal evidence which suggested that he was struggling with his predicament. His only request for assistance at this time was when he provided a small handwritten note to FCCC Farrell, indicating that he was fearful for his safety if it became known within the prison population that he had implicated his co-offenders.

155 That request was treated seriously and appropriately by both FCCC Farrell and CO Quinlan. Joel was moved to a ‘one out’ cell, Cell 4, while his application to be moved to SMAP was processed.

156 Various correctional officers involved in the inquest believed that it was necessary for an inmate to complete a written application before they could be transferred to a SMAP or ‘protection’ placement. It became clear that CSNSW policy does not require an inmate to provide a written application in those circumstances.

157 Somewhat disingenuously, the court was led to believe that the Assessment Tool – Inmates under Threat was to be completed by senior officers, when in fact, any correctional officer was authorised to complete the assessment.

Indeed, FCCO Coll subsequently indicated that she was aware of the union’s directive that correctional officers should not complete the paperwork as part of an industrial dispute and acted on that directive.

158 It is not possible to conclude that Joel’s application would have been processed more quickly or in a different fashion if another correctional officer, apart from SAS Duckworth had reviewed the application.

159 Governor Nicholson confirmed in her oral evidence that it would have been possible to have processed Joel’s application within 1 – 1.5 hours after receipt of the handwritten note. Effectively, his application could have been completed prior to the day staff finishing their shift. If a suitable ‘one-out’ cell had been available within the SMAP unit, Joel could have been transferred to SMAP on 24 July 2022.

160 Instead, SAS Duckworth decided to leave Joel’s application in abeyance, while he waited for another functional officer to commence his shift the following morning.

161 Mr Brown indicated that it was not a foregone conclusion that Joel would have been assessed as being suitable for SMAP and may have required a higher level of protection.

162 It is unknown whether his placement in SMAP on the afternoon of 24 July 2022, may have assuaged Joel’s concerns and positively impacted his low mood.

163 It is clear that in these circumstances, Joel was left by himself for 18 hours without human contact or wellbeing observations by corrections officers.

Governor Nicholson indicated that staffing shortages and overall funding, do not allow for cell observations for inmates who have not declared, or been assessed, as being at risk of self-harm.

164 It is quite extraordinary that young, vulnerable inmates are left for such lengthy periods of time without human contact. It is also quite extraordinary that inmates are provided with their dinner at around 2pm, with no additional food being provided until breakfast at 7 am, some 17 hours later.

165 Inmates are deprived of their liberty, however, should not be exposed to unnecessary hardship and deprivation, including the timeliness of the provision of food.

166 The availability of ligature hanging points has been the subject of various deaths in custody inquests. The NSW Coroner’s Court has been advised repeatedly by CSNSW that these issues are being addressed with an ongoing capital works program. It is of significant concern that Perspex had been placed over the bars of the cell door, exposing a 10 cm gap, which permitted Joel to tie his bed linen to the bars in that gap. It is unclear whether the use of Perspex was part of the capital works program. It is also of concern that Cell 4 has not been decommissioned but is simply no longer operational at this time.

Recommendations 167 At the conclusion of the evidence, two draft Recommendations were provided to the legal representatives for the Commissioner of Corrective Services NSW and Joel’s family by counsel assisting.

168 The two recommendations focus on the need for the training of staff regarding an inmate’s request for protection or a SMAP placement and the appropriate timeframe for the completion of the Assessment Tool – Inmates under Threat.

169 Notwithstanding the industrial dispute, there appeared to be some uncertainty by correctional officers who was authorised to complete the Assessment Tool – Inmates under Threat. In addition, there needs to be clarity amongst functional officers so that one functional officer does not undertake the Assessment Tool – Inmates under Threat, and then subsequently approve their own recommendations.

170 The two recommendations proposed by counsel assisting directed to the Commissioner of Corrective Services are as follows: Recommendation 1: That CSNSW provide training to frontline correctional officers in respect of the management of an inmate’s request for protection or alternative cell placement, including in respect of: a. The applicable policies; b. the person’s authorised to administer the Assessment Tool – Inmates under Threat.

c. The requirement or expectation that the Assessment Tool – Inmates under Threat be administered as soon as reasonably practicable or, in the event of policy amendment, within the stated period for completion.

Recommendation 2: That CSNSW reviews its policies and consider imposition of a requirement that where it is determined that an inmate may be at risk or require alternative cell placement completion of the Assessment Tool – inmate under Threat occur within four hours unless in exceptional circumstances.

171 On behalf of the Commissioner of Corrective Services NSW, the first proposed recommendation was not opposed.

172 In respect of the second proposed recommendation, the Commissioner of Corrective Services NSW sought that the phrasing of the recommendation be amended slightly as follows (amendments to counsel assisting’s proposed recommendation are underlined): Recommendation 2: That CSNSW reviews its policies and consider imposition of a requirement that where it is determined that an inmate: a. may be at risk from others; or b. requires alternative cell placement as a result of a threat to the personal safety of the inmate; or c. requires alternative cell placement as a result of a request by the inmate due to fears for their personal safety;

completion of the Assessment Tool – Inmate under Threat, occur within four hours unless in exceptional circumstances.

173 I accept the changes proposed by the Commissioner and adopt this as the final recommendation.

174 I am of the view that it is appropriate to make the proposed Recommendations to the Commissioner of Corrective Services NSW, pursuant to section 82 of the Coroners Act 2009 (NSW).

Conclusions 175 Joel was a young, vulnerable inmate who had never experienced the hardships of a custodial setting prior to his incarceration in 2022.

176 Joel’s mood appeared to deteriorate on 23 July 2022, during his AVL call with his partner, Ms L. He did not complain to anyone that he was experiencing thoughts of self-harm after that call. He did positively assert that he believed that he needed to be relocated to the SMAP wing for his safety.

177 Increased staffing levels and funding may have permitted periods of observation of Joel in Cell 4, however, this is predicated on him indicating that he had concerns about his mental health.

178 I am satisfied that at the time of his death, Joel was lawfully in custody.

179 Joel’s family gave a compelling and eloquent family statement. Their distress and advocacy have been boundless.

180 It is clear that Joel was an important and integral part of his extended family.

He was greatly loved, and his death has caused much suffering amongst his family and friends.

Closing Observations 181 Before turning to the findings that I am required to make, I would like to acknowledge my gratitude to Mr Matthew Robinson of counsel and Ms Rebecca Campbell, solicitor, for their significant assistance, commitment, support and preparation of this case.

182 I would also like to acknowledge and thank the Officer in Charge of this investigation, Detective Senior Constable Kelli Moller for her assistance and commitment.

183 Finally, I would like to again record my most sincere condolences to Joel’s family.

Findings pursuant to section 81(1) of the Coroners Act

2009 (NSW) 184 I make the following findings pursuant to section 81 (1) of the Coroners Act 2009 (NSW) using now the pseudonym SF instead of the name, Joel, used throughout these findings: The identity of the deceased 185 The person who died was SF.

Date of Death 186 SF died between 2.35pm on 24 July 2022 and 8.34am on 25 July 2022.

Place of Death 187 SF died at the Goulburn Correctional Centre, Goulburn NSW.

Cause of death 188 The cause of SF’s death was Hanging.

Manner of Death 189 The manner of SF’s death was a self-inflicted injury with the intention of ending his life.

Recommendations 190 I make the following recommendations pursuant to section 82 of the Coroners Act 2009 (NSW): To the Commissioner Corrective Services NSW

1. That CSNSW provide training to frontline correctional officers in respect of the management of an inmate’s request for protection or alternative cell placement, including in respect of: a. the applicable policies; b. the persons authorised to administer the Assessment Tool – Inmates under Threat; and

c. the requirement or expectation that the Assessment Tool – Inmates under Threat be administered as soon as reasonably practicable or, in the event of policy amendment, within the stated period for completion.

2. That CSNSW reviews its policies and consider imposition of a requirement that where it is determined that an inmate: d. may be at risk from others; or e. requires alternative cell placement as a result of a threat to the personal safety of the inmate; or, f. requires alternative cell placement as a result of a request by the inmate due to fears for their personal safety; completion of the Assessment Tool – Inmate under Threat, occur within four hours unless in exceptional circumstances.

191 I now close this inquest.

Magistrate Joan Baptie Deputy State Coroner 8 July 2025