Inquest into the death of Vernon Bonson

CITATION: Inquest into the death of Vernon Bonson

[2018] NTLC 006 TITLE OF COURT: Coroners Court JURISDICTION: Darwin FILE NO(s): D0136/2016 DELIVERED ON: 7 February 2018 DELIVERED AT: Darwin HEARING DATE(s): 22, 23 January 2018 FINDING OF: Judge Greg Cavanagh CATCHWORDS: Death in custody, hanging from fan in correctional facility, department developing solution to prevent fans holding body weight, recording of reasons for transfer of prisoners within prison

REPRESENTATION: Counsel Assisting: Kelvin Currie Counsel for Correctional Services Helena Blundell Counsel for family Chris McGorey Judgment category classification: A Judgement ID number: [2018] NTLC 006 Number of paragraphs: 64 Number of pages: 12

IN THE CORONERS COURT AT DARWIN IN THE NORTHERN TERRITORY OF AUSTRALIA No. D0136/2016 In the matter of an Inquest into the death of

VERNON BONSON ON 25 AUGUST 2016 AT DARWIN CORRECTIONAL PRECINCT HOLTZ FINDINGS Judge Greg Cavanagh Introduction

1. The deceased (“Mr Bonson”) was born 21 May 1985. He was 31 years old at the date of his death. He was born at the Royal Darwin Hospital to Dawn Walamana Pascoe and Terry Bonson. He was the third of four children. He had a sister and two brothers.

2. He grew up in Maningrida and went to School there. For a time he worked for the Bawinanga Aboriginal Corporation in both the workshop and collecting rubbish around the community.

3. He married his first wife, Raylene Gaykamangu in 2008. Together they had two children, Shannon and Gail. They separated after about three years.

4. In 2009 he was involved in a motor vehicle accident. He was driving a troop carrier on his father’s outstation when ran into a tree at 120 kilometres an hour. He wasn’t wearing a seatbelt and hit the windscreen. He hurt his head and the left side of his chest. He said he was dizzy for two to three months after the crash.

5. Thereafter he reported having blurry vision, headaches and was occasionally dizzy.1 He thought he might have injured his brain. He said he had memory problems and his family was concerned his personality had changed.2

6. Mr Bonson and his family told the Health Clinic of concerns about his loss of control and potential for violence. There were concerns that he had poor impulse control and an inability to manage his feelings and behaviours.3

7. On 8 August 2010 there was an argument between Mr Bonson and his wife.

He grabbed an electric cord and said he was going to hang himself. The police were called. They found him. By that time he had calmed down.

8. During 2013 he entered into a relationship with Mickaela Pascoe.

9. While in Darwin on 13 August 2015, Mr Bonson became aggressive toward Mickaela. He punched her, hit her with a chair and a stick, hit her head into the pavement and into a fence, choked her and threatened to stab her with scissors.

10. Police intervened, arrested him and charged him with aggravated assault and threatening to kill. He was convicted of the aggravated assault and imprisoned for five months.

11. The following day, 14 August 2015, a Domestic Violence Order was served on Mr Bonson for the protection of his wife Mickaela. It had a no contact order whilst he was intoxicated.

12. On 1 May 2016 Mickaela gave birth to a daughter. They named her Jerricah.

13. In June 2016 Mr Bonson formed the belief that his brother-in-law, had tried to sleep with his wife. His wife denied it, but requested that Police help 1 Medical Notes 12 June 2015 2 Medical Notes, request for CT Scan brain 3 Medical Notes 9 January 2015, 11 February 2015, 6 July 2015

facilitate a mediation between the families. Mr Bonson did not attend mediation and continued to make allegations.

14. On Saturday 16 July 2016, Mr Bonson and Mickaela had an argument during which he raised a frying pan toward her and pushed her in the chest, backing her up against a window. She was conveyed by relatives to the Maningrida Women’s Safe House along with their two month old daughter.

15. The following day Mr Bonson stood outside the Safe House calling out to his wife to bring the baby out. He then asked his sister, to collect his daughter so he could see her. His sister refused and he threatened harm to his sister and self-harm.

16. On 18 July 2016 he was arrested by Maningrida Police and charged with:

• Aggravated Assault

• Engage in conduct that contravenes DVO

• Breach Bail

• Drive MV while disqualified

• Drive High Range

17. On 19 July 2016 he met a lawyer, Ms Beth Morrisroe from the North Australian Aboriginal Justice Agency (NAAJA), at the Darwin Local Court.

Ms Morrisroe made enquires with family about a bail plan. The plan formulated was that if granted bail he would take the next flight to Maningrida where he would reside with his Aunt until a vehicle was available to take him to Gamardi Outstation. He would stay there until the hearing date at Maningrida.

18. However due to a significant history of domestic violence and the presumption against bail, he was refused bail and remanded in custody. It was his 7th episode in prison.

19. Initially he was allocated a default medium security classification in Sector 5, pending security assessment. The next day he was assessed and classified as Low 1 security. The day after he was transferred to Sector 6, a low security sector. He stayed in Sector 6-E-1 for just over a month.

20. On 21 August 2016 Mr Bonson made a request to see a NAAJA lawyer. He told the lawyer that he wanted to report sexual assaults on his wife and his ex-wife. He said that his wife had been sexually assaulted by his brother-inlaw. He said his first wife had been made to do a sex movie by his uncle.

The lawyer notified the Police that Mr Bonson wished to speak to them.

Sergeant Rob James commenced making enquiries.

21. On 23 August 2016 Mr Bonson was transferred to Sector 5-D-1. There is no indication on Prison records as to why that occurred. However there is a statement on the brief by SCO Ryan McCarthy indicating that transfer was at the request of Mr Bonson. He told SCO McCarthy he had no family in Sector 6 and wished to be transferred to Sector 5.

22. At 9.30am on 24 August 2016 Mr Bonson met with Sergeant James in the prison reception area. He told Sergeant James about the sexual assaults and said he had been told about them by his sister. Sergeant James told him he had contacted the Maningrida Police and asked that they talk to his wife and ex-wife about the allegations and detectives may wish to take a statement from him later.

23. At 11.59am Mr Bonson made a phone call to his wife. The call lasted two minutes. They spoke in language. At the time his wife was walking home after picking up their baby from day care. They spoke of money and providing money for the children of his first marriage as well as the baby.

He asked her if she could get him a lawyer to bail him out and whether she could attend court on the 7th with the baby so he could see the baby. He said he was looking at being inside for 4 – 6 months but was hopeful of 2 – 3

months. He finished up asking her to pray for him saying he would hopefully be home soon.

24. At 1.00pm he was transferred to Sector 6-C-5, room 4. The reasons for that move are not known. In that block was his cousin, Nelson. In the room he was allocated was Nelson’s nephew. In addition to having family in his accommodation area, Mr Bonson also saw and mixed with other family in Sector 6 that afternoon.

25. At 3.23pm Mr Bonson phoned his uncle, Andrew Diwardi. Although the call lasted 10 minutes the majority of that was between another inmate, Malcolm Brown, and his uncle.

26. While Mr Bonson was on the phone talking to Andrew he said he needed support from the community for his bail. He said there was big trouble just before he left and asked if his Uncle if he could sort it out with the family at Ramingining with whom he was arguing.

27. At 5.30pm Mr Bonson made another phone call. He rang his uncle, Andrew Diwardi, again. He asked to speak to his son Shannon. Shannon was given the phone and he spoke to him for a short time and then asked his son to get his uncle to the phone. Another uncle took the phone and there was talk about which number to call. Evidently Mr Bonson had rung previously and the call hadn’t been accepted.

28. A different number was provided. Mr Bonson then handed the phone to another inmate, Esau. The call lasted six minutes although for the majority of that time Mr Bonson was in the background. It ended with laughter.

29. Mr Bonson went to where a number of other prisoners were playing cards just outside the kitchen area. He sat next to his cousin, Nelson and spoke to him. He spoke about wanting to get back home to see his children and wife.

Nelson told him while in prison not to think about the outside, not to think too much, but to pray to god until his release.

30. Nelson said that the main concern of Mr Bonson was an allegation that he had raped his ex-wife and his wife. He said he was worried he would get 15 years in prison. Mr Bonson seemed preoccupied and spent a lot of time writing on paper and reading what he had written.

31. At dinner Mr Bonson seemed upset. He left most of his food in the fridge.

The other inmates suggested that Nelson go and have a chat to him. Nelson went to Mr Bonson’s room at 6.18pm. Mr Bonson told him the same story about the allegation of rape and his concern he may spend 15 years in prison. He said his uncle asked him why he raped his niece and daughter.

Nelson said Mr Bonsons was telling the same story over and over. Nelson said to him, “don’t think too much, don’t stress out”.

32. Just outside room 4 (the room Mr Bonson was allocated) in the hallway, is a CCTV camera. There is a second camera in the communal area. The only time the cameras could not follow the movement of Mr Bonson was when he was in his room and away from the doorway or when he was in the toilet area.

33. That night the other inmates watched a James Bond movie. Mr Bonson didn’t join them. He stayed primarily in his room. What is obvious from watching the CCTV recordings is that Mr Bonson was very unsettled. He did not sleep that night. He is seen to be pacing in his room, in the hallway and the communal area. He is often seen going in and out of his room, either to the toilet area or the communal area.

34. He got the bible from the shelf in the room on a number of occasions. He also got paper and a pen on many occasions. He sometimes propped the door open and sometimes closed it. Sometimes had the light on and then not long after, turned it off. He spent quite a bit of time in the communal area, turning the TV on and off, writing, ripping up a dish cloth, doing press ups and reading the bible.

35. At 7.14pm, 7.19pm, 10.46pm, 1.13am, 1.55am, 2.04am, 2.10am and 3.00am he is seen ripping or folding paper (often tearing it from an exercise book) and then putting it in the kitchen bin or going to the toilet area with it.

36. Inmates often slept in a screened area on a balcony. It was cooler. Mr Bonson’s roommate, Sebastian, took his mattress and pillow to the outdoor sleeping area at 10.45pm.

37. The CCTV recording shows that from that time no other person entered room 4 that night. After that time, Mr Bonson is seen to be moving from one place to the other very regularly. He was generally the only one awake.

38. At 2.54am he took his pillow to the communal area and lay down on the couch with it under his head. Five minutes later he returned to his room, took a folded piece of paper from the waistband on his shorts and went to the toilet area. He returned to the communal area without the paper and then two minutes later returned with his pillow to his room.

39. He removed chocks that he had under the door and closed it. He then left the room, pushing the light switch in the hallway on his way to the communal area. He checked the light switch in the kitchen. Picked up the TV remote and switched on the TV, a few seconds later he switched it off. He returned to his room and closed the door behind him. The light was off. The time was 3.07am. He did not reappear.

40. At 6.28am his roommate returned to the room with pillow in hand. He opened the door and was in the process of putting a thong between the door and the door jamb to keep the door open when he stopped, looking straight ahead for a couple of seconds, and then quickly left. A minute later Nelson looked through the glass in the door and left. He called the radio operator and reported that Mr Bonson had hung himself.

41. The Correctional Services Officers arrived at 6.36am. They found him hanging from a length of torn sheet attached to the overhead fan. He had his

shirt around his head covering his face. There was a plastic chair nearby.

The officers cut him down and commenced Cardio Pulmonary Resuscitation (CPR). Police were notified at 6.39am. The ambulance officers arrived and took over resuscitation at 6.53am. He could not be revived and was declared deceased at 7.07am.

42. Sitting on the top bunk was a piece of paper, folded twice. Written on it was the following: “lawyer beth morrison and the mgd police think imma raper they think I rape my first wife Raylene Murphy and my second wife Mickaela Pascoe but they got it wrong I never rape any woman whole my life even my wives till today. When I had my last little angel.

JPB may god bless you my little one (cid:1)♥(cid:1)”

43. The last sentence appeared to have been added, possibly while writing on a different surface.

44. Police arrived at 8.00am and set up a crime scene.

45. Beth Morrisroe and the Maningrida Police did not discuss with Mr Bonson allegations of rape against him or receive a complaint or other information to that effect. It appears that if the allegation was made, it came from a family member.

Issues Load sensing device fitment to fans

46. This was the second hanging involving the overhead fans in the new prison (completed September 2014). The inquest into the first such death, the death of Roy Melbourne, was held on 26 June 2017. My findings in relation to that inquest were published on 26 July 2017. I recommended that the Commissioner of Correctional Services ensure that the risk posed by the fans in the Darwin Correctional Precinct being used as hanging points be mitigated by the fitting a load sensing mechanism or other similar device.

47. Due to unexpected delays the overhead fans were removed from the single occupancy cells in December 2017 and replaced with desk fans. However they were not considered to be as good as the overhead fans and were attracting a number of complaints.

48. I was told that there have been a number of difficulties in obtaining such a mechanism or device, but that one has been developed and is in the final stages of testing and approval. That was expected to be finalised in a matter of days.

Recording of reasons for transfer within the prison

49. The Darwin Correctional Precinct utilises computer software called “IOMS” to record a number of things including transfer of prisoners. However I was told that it does not require the reason for the transfer to be included in all cases.

50. After the death of Mr Bonson the Correctional Services Officers started a chart to record the reasons for transfer. That recognised the gap in the processes.

51. The Commissioner of Correctional Services advised that IOMS will be expanded so as to record the rationale for movements in accommodation. He said that it would be, “enhanced to not only include the warning flags but to also expand on the data recorded against an offenders accommodation movements, including date and time of movement, reason for movement and user details. The review is currently underway with a plan to implement the changes in the near future.” Hanging points more generally

52. The family of the deceased raised the issue of the other hanging points in the room. Their main concern was the bunk beds that were of a bent metal construction and provided many hanging points. They urged that the hanging points be minimised.

53. It was explained by the Commissioner that there is a balance that needs to be struck in the low security areas of the prison. The balance is between normalising the living conditions for inmates and minimising hanging points.

54. There are many hanging points in the rooms and the communal areas.

Having doors on the rooms and allowing free access around the inside and outside of the housing block inevitably means that there are hanging points. In addition, the bunks, the table and chair in the room create additional hanging points.

55. Where that balance should be struck is not a matter for this inquest. It is a policy decision for Correctional Services who are expected to be experts in such areas or able to access that expertise. If there are good reasons to question those decisions that can be done. However that was not an issue investigated or upon which there was expert evidence available to this inquest.

56. The issue with the fans is in my view different. Overhead fans pose an obvious risk as hanging points. They are known to have been used as hanging points in the past. I have referred to them previously as a “classic” hanging point.

57. However, a determination as to mitigating that obvious risk does not require consideration of the balance between a therapeutic environment and an oppressive one. It is not suggested the fans be removed. What is suggested is, simply, that they be installed in a manner so they cannot hold the weight of a person and cannot therefore be used as hanging points.

Care, Supervision and Treatment

58. Section 26(1)(a) of the Coroner’s Act requires that I must investigate and report on the care, supervision and treatment of the deceased while he was being held in custody.

59. The evidence was to the effect that at no time in his interactions with the Correctional Services personnel did Mr Bonson show any indications of self-harming. In fact neither did he give his family the impression that he was thinking of self-harming.

60. There was no information as to why Mr Bonson was transferred back to Sector 6 a day after he transferred at his request to Sector 5. At first blush that might have been thought to have potentially contributed to his decision.

However, the evidence in relation to how that movement took place indicates that Mr Bonson made no complaint in relation to that move. The Correctional Services Officer noted: “Prisoner Bonson came up to the window and asked if it was ok for him to go now, I advised him to take a seat as they asked if we could wait 5 minutes, he did not complain or question the move.

He sat and patiently waited, when it was time to go he and the other prisoner got up and walked out with no issues.”

61. He ended up in a room with family and with another family member in the same premises. It was a family member he sought out for advice. He also had opportunity on that same afternoon to talk to family on the phone along with other members of his extended family in Sector 6 with whom he interacted.

62. There is no criticism that can or should be made of the prisoner officers involved with his care and supervision. In my view the care supervision and treatment of Mr Bonson was adequate.

Formal findings

63. Pursuant to section 34 of the Coroner’s Act, I find as follows:

(i) The identity of the deceased was Vernon Bonson born 21 May 1985 in Darwin.

(ii) The time of death was between 3.07am and 6.28am on 25 August

2016. The place of death was Room 4 Block 6-C-5, Darwin Correctional Precinct, Holtze, Northern Territory.

(iii) The cause of death was self-inflicted hanging.

(iv) The particulars required to register the death:

1. The deceased was Vernon Bonson.

2. The deceased was of Aboriginal descent.

3. The deceased was a prisoner and not employed at the time of his death.

4. The death was reported to the Coroner by the Darwin Correctional Precinct staff.

5. The cause of death was confirmed by Forensic Pathologist, Dr John Rutherford.

6. The deceased’s mother was Dawn Walamana Pascoe and his father was Terry Bonson.

Recommendation

64. I recommend the Commissioner of the Northern Territory Correctional Services ensure that the reasons for the transfer of prisoners within the Correctional Precinct are recorded.

Dated this 7th day of February 2018.

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GREG CAVANAGH TERRITORY CORONER