Coroner's Finding: STURT Royston Henry

CORONERS ACT, 1975 AS AMENDED SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Port Augusta and Adelaide in the State of South Australia, on the 11th and 12th days of October, and 28th day of November, 2000, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Royston Henry Sturt.

I, the said Coroner, do find that Royston Henry Sturt, aged 58 years, late of Port Augusta Prison, Port Augusta, in the State of South Australia, died at the Port Augusta Prison on the 14th day of January, 1998 as a result of hanging. I find that the circumstances of death were as follows:-

1. Reason for inquest 1.1 On 3 April 1997 Royston Henry Sturt was arrested and charged with the murder of Renee Frodsham, who disappeared from the Westlands Shopping Centre car park in Whyalla on 17 March 1980. On 10 September 1997, Mr. Sturt was committed for trial in the Supreme Court of South Australia on that charge. Bail was refused. Mr.

Sturt was remanded in custody and was awaiting trial at the time of his death on 14 January 1998. Accordingly, he was “detained in custody” pursuant to an Act or law of this State within the meaning of Section 12(1)(da) of the Coroners Act, and an inquest was therefore mandatory pursuant to Section 14(1a) of that Act.

2. Background 2.1 The background leading to Mr. Sturt’s arrest for the murder of Mrs. Frodsham, the circumstances of the discovery of her grave site, and the general background to the criminal charges, have been examined in detail in my finding in the inquest into Mrs.

Frodsham’s death (Inquest No.38/89).

2.2 Mr. Sturt was born in England on 29 November 1939. He came to Australia with his wife Joan in 1966 and soon moved to Whyalla, where he gained employment with the Broken Hill Pty. Co. Ltd., where he worked for 26 years.

2.3 In 1992 the marriage broke down, and Mr. and Mrs. Sturt separated.

2.4 Mr. Sturt was interviewed by police at the time of Mrs. Frodsham’s disappearance in 1980, since the Sturts and Frodshams lived next door to each other. He denied all knowledge of her disappearance at that time.

2.5 After he was arrested at Whyalla on 3 April 1997, and remanded in custody, he was conveyed to the Adelaide Remand Centre until 6 June 1997. He was then transferred to the Port Augusta Prison in order to be closer to his family who were travelling long distances to visit him every weekend. He remained at Port Augusta Prison until 8 July 1997, when he was transferred back to the Adelaide Remand Centre until 15 July 1997 due to court commitments. He was transferred back to the Port Augusta Prison on 15 July, where he remained until his death.

3. Admission to prison 3.1 Mr. Sturt was admitted to the Adelaide Remand Centre on 4 April 1997, and was examined by a Registered Nurse. An entry in the casenotes reads:- “New admission to ARC. Recent history of exacerbation of depression. Taking Prozac 20mg mané - prescribed by local G.P. Denies suicidal ideation. Wife contacted DCS stating Mr. Sturt has been expressing suicidal ideation. Whilst interviewing Mr. Sturt he was agitated, looked tearful, though denied feeling this way; also stated he felt ‘shellshocked’. Admit to infirmary, to be reviewed by M.O. this evening ...”.

(Exhibit C.38).

3.2 Mr. Sturt was admitted to the infirmary, but he declined the chloral hydrate medication which had been offered in accordance with the doctor’s directions.

3.3 Mr. Sturt was discharged from the infirmary on 8 April 1997.

3.4 Mr Sturt was seen by Dr Ken O’Brien, Director of Forensic Psychiatry, on 17 June 1997, who found ‘no evidence of depression or obvious mental illness’. Dr O’Brien added: “Denies suicidal thoughts. Happy to come off Prozac. I concur. Is familiar with his symptoms (mood swings, he claims) and if they return he will alert medical/nursing staff. As a precaution I will review him in 2/12”.

3.5 When Mr. Sturt returned to Port Augusta Gaol on 15 July 1997 he denied any intent to self-harm, and declined to see Dr. O’Brien again.

3.6 He was reviewed by the psychiatric nurse on 20 August 1997 and “appears calm and happier”.

3.7 There is no further mention in the Medical Progress Notes concerning Mr. Sturt’s emotional state from 20 August 1997 to the date of his death on 14 January 1998.

3.8 The totality of this evidence suggests that Mr. Sturt’s history of depression was noted upon his admission, was treated appropriately by admission to the infirmary for several days and observation, and by follow-up examination with a consultant psychiatrist. He was followed up again in Port Augusta Prison, and, it appears to me that insofar as the Department of Correctional Services is concerned, there was no information before them which indicated that Mr. Sturt was at particular risk of suicide.

4. Signs of depression 4.1 Mrs. Joan Sturt said that she visited her husband at the Port Augusta Prison every weekend. She said that he had been “bewildered” and “edgy” and possibly depressed while he was in the Adelaide Remand Centre, but he improved at Port Augusta and “seemed to me to be making the best of the situation. At no time did Roy indicate to me that he intended to harm himself” (Exhibit C.5a, p3).

4.2 His daughter Judy agreed that Mr. Sturt was not happy at the Adelaide Remand Centre but was better at Port Augusta. She said that he had been upset because he had been having difficulties getting access to information which he said would help his defence. However, on no occasion did he indicate any intention to harm himself (T.18). The other daughter, Alison Sturt, also agreed that Mr. Sturt’s mood improved at Port Augusta. She visited him on the Saturday and Sunday before he died, and noticed nothing specific about his emotional state. She added that her father had expressed frustration from time to time about the diet he was receiving in prison, the difficulties he was having gaining access to his lawyer, and the fact that he did not feel that he had been given sufficient time to prepare for his trial in March of that year. Despite these difficulties, he still preferred to be in Port Augusta rather than the Adelaide Remand Centre (T.23, T.30).

4.3 Ms. Aileen Daniel, the Education Officer at Port Augusta Prison, had a good deal of contact with Mr. Sturt while he was awaiting trial. She said that he mentioned the fact that a friend of his had been killed in a motor cycle accident recently, and he seemed a little distressed about that (Exhibit C.11a, p1). However, she said that she was shocked to hear of his death and that she was in “disbelief” (Exhibit C.11a, p1).

4.4 Raymond Gray, another inmate, said that Mr. Sturt had been “a bit more withdrawn than usual” in the last week and a half or so (Exhibit Cl9a, p1). He also mentioned that Mr. Sturt had seemed depressed about his friend’s motor cycle accident (Exhibit C.19a, p3). He also found it “hard to believe” that Mr. Sturt would have taken his own life (Exhibit C.19a, p3).

4.5 Dwayne Maynard, another prisoner, said that he became close to Mr. Sturt in Port Augusta Prison. He also mentioned Mr. Sturt’s distress over his friend’s death in the motor cycle accident, and the fact that Mr. Sturt had been dressing untidily and not shaving nor brushing his hair since that time (Exhibit C.23a, p1). He saw Mr. Sturt on the day before he died and said:- “He did not mention or give any indication that he would harm himself, nor has he ever done so to me”. (Exhibit C.23a, p2).

4.6 On 7 November 1997, Mr. Sturt handed his solicitor, Mr. Stephen Ey, a sealed envelope. Endorsed on the envelope were hand-written instructions that the envelope was to be opened only in the event of Mr. Sturt’s death. After he was advised of Mr.

Sturt’s death, Mr. Ey contacted the police and handed the contents of the envelope to Detective Kinsman. The envelope contained a number of smaller envelopes addressed to various people. All of the letters are written in contemplation of death, although they do not indicate that Mr. Sturt thought his death was necessarily imminent.

For example:-

• in a letter dated 1 November 1997 to the General Manager of Port Augusta Prison, Mr. Sturt said:- “I am not sure whether I have made a blot on your establishment’s record by the time you receive this or not, so this only applies if in fact I have done so. ... Your establishment and personnel bear no responsibility for what has occurred ...”.

• In a letter to Mrs. Sturt dated 2 November 1997, Mr. Sturt said:- “The world will think this is some sort of admission, which of course it is; but not the admission that the world will think. It’s an admission that I am worn out ...”;

• In a letter dated 1 November 1997 to Mr. Ey, Mr. Sturt said:- “In the normal course of events, I would, of course, be in a position to talk about these things, even in court or afterwards, and this is most likely to happen. However, things happen in these places, and I wish to be quite clear that these things get said whether or not I am around to say them”.

In his statement, Mr. Ey said:- “Although Royston Sturt never said anything to me about intending suicide, he did on occasions appear very depressed”. (Exhibit C.27a, p2).

4.7 One person who was not equivocal about Mr. Sturt’s emotional state was Ms. Natasha Appleby, who had been having a relationship with Mr. Sturt since the early 1990’s.

She gave evidence that Mr. Sturt was significantly depressed throughout their relationship. She said that he would go into what she described as “black holes” which lasted for days. She said that he told her that this had been happening for many years (T.34). During these “incidents”, she said he would become inactive and uncommunicative, and would not eat or drink.

4.8 Ms. Appleby said that Mr. Sturt discussed suicide with her virtually every time she visited him in gaol. She said:- “He just couldn’t handle the confinement”. (T.35).

4.9 Ms. Appleby said that his depression became gradually worse. She said that, at Christmas 1997, he told her:- “This is the last Christmas Day we will ever spend together”. (T.35).

4.10 Ms. Appleby said that she did not report Mr. Sturt’s emotional state to the prison authorities. She said that she discussed it with Alison Sturt (T.36).

Ms. Sturt said that she telephoned the Port Augusta Gaol and was put through to David Thompson, a social worker, and told him that she was concerned about her father, and in particular that he had ceased taking his medication with their permission. She said that Mr. Thompson said that he would go and see her father and keep an eye on him.

4.11 Mr. Thompson said that he recalled receiving a telephone call from Mr. Sturt’s daughter while Mr. Sturt was still in Adelaide. He was unable to recall the substance of the telephone call or any action he took as a result of it. He said that there had been a “clear out” of records at Port Augusta Prison since that time, and he could find no documentation concerning Mr. Sturt.

4.12 Ms. Appleby said that Mr. Sturt told her that he had seen a social worker “at least once”, although she could not elaborate (T.58). I think it is fair to conclude that Mr.

Thompson probably did follow up from Ms. Sturt’s call, and saw Mr. Sturt, but that nothing of particular significance transpired from that.

4.13 Mr. Sturt was seen many times during the period in question in the Port Augusta Infirmary in relation to problems he was having with his ears, and nothing untoward was noted. Clinical Nurse Consultant Linda Plumb said:- “On 14 August 1997 Sturt’s file was reviewed by Dr. O’Brien. On 20 August 1997 he was examined by Registered Nurse Joyce Kennedy, and stated that he had no thoughts of self-harm. From 14 October 1997 to 18 November 1997 Sturt saw nursing staff eight times and Dr. Schroff three times in all for an ear problem which culminated in Dr.

Schroff advising the ear was clear”. (Exhibit C.9a, p2).

I am satisfied that if there was any concern about Mr. Sturt’s emotional state, it would have become apparent during this period.

4.14 Mr. Sturt was an intelligent and self-possessed man who, from the material before me, clearly thought that he was in control of his own situation and indeed the people around him. When asked by Mr. Ey, counsel for the Sturt family, why she did not communicate with the prison authorities, she replied:- “Because he asked me not to”. (T.44).

She added:- “It wouldn’t have done any good anyway, if he wanted to kill himself you wouldn’t have stopped him. He would have done it in any event. He would have run circles around a

social worker and I know that sounds awful but it’s true. He would have. You wouldn’t have stopped him, I wouldn’t have stopped him, no one would have stopped him because that’s who he was. Once Roy made up his mind to do something he would do it”.

(T.47).

4.15 In summary, then, Ms. Appleby is the only witness who has described overt statements by Mr. Sturt that he intended to kill himself. Mr. Ey questioned Ms.

Appleby’s reliability, since she suffers from mental illness herself. However, I see no reason to reject her evidence. She became upset when giving evidence, but showed no signs of mental illness, and her evidence about times that she visited Mr. Sturt in prison was verified by prison records when challenged by Mr. Ey. I do not find it surprising that Mr. Sturt would have said these things to Ms. Appleby but not to his wife or daughters, or indeed anyone else. The impression I have is that Mr. Sturt was a highly manipulative person, and a very effective way of connecting with, and manipulating Ms. Appleby would have been to talk to her about emotional issues.

4.16 In summary, then, there is no evidence before me that the authorities at Port Augusta Prison knew, or should have known, that Mr. Sturt was suicidal, nor is there any other ground for criticising the way in which Mr. Sturt was treated there. Indeed, in the letter he wrote to the General Manager of the Prison, which I have already mentioned, he was complimentary about the treatment re received there.

5. Events of 14 January 1998 5.1 Correctional Officers Philip Stone and Terence Hopgood constituted the second watch patrol on the evening of 13 to the morning of 14 January 1998. They received a handover at 11.50p.m., and Mr. Stone conducted a handover count of Unit 3 in Bluebush Wing and inspected Cell G11, occupied by Mr. Sturt. He said:- “I saw a body in bed”. (Exhibit C.36, p1).

5.2 Mr. Hopgood inspected Cell G11 at 1.55a.m. and 4.00a.m., and “I observed what appeared to be a prisoner covered by a blanket” (Exhibit C.35, p1).

5.3 At 6.10a.m. Mr. Stone made the same observation in Cell G11 (Exhibit C.36, p2).

5.4 At about 8.15a.m. Correctional Officer Michael Obst opened the door to Cell G11.

His observations were as follows:- “It was then I noticed a hand on the end of the bench, the bench is situated on the left hand side of the cell and he had a computer and other personal belongings stacked on top

so it made it difficult to see anything else at that stage. I thought this was odd as I noticed the bed was made up to look as though someone was sleeping in it. I then looked on the floor for any blood but could not see any. I then walked in the cell and saw prisoner Sturt hanging with a bit of white sheet wrapped around his neck and the other end tied to the top shelf which is approximately only 5 ½ foot in height. I noticed he was naked and his feet were touching the ground, he was in a kneeling position with his knees approximately 6 inches from the ground”. (Exhibit C.13a, p1).

5.5 In fact, a total of seventeen blankets were found by Detective Husdell, the Investigating Officer. They had been used to form a very convincing mannequin, to mislead Correctional Officers into thinking that Mr. Sturt was asleep. No explanation has been given as to how Mr. Sturt obtained that many blankets.

5.6 Correctional Officer Bowey then entered the cell and began looking for a pulse whilst Obst called a “Code Black” on the radio, indicating a medical emergency. Mr. Bowey noted that Mr. Sturt was cold and that there was no pulse (Exhibit C.12b, p2).

5.7 Within about three minutes Registered Nurses Plumb and Kennedy arrived. Ms.

Plumb said:- “I saw he wasn’t suspended and hanging freely from a high point for example, he was in contact with the floor with an arm resting on his bench. I noted the colour of his skin on the upper body was yellow/white and his legs were mottled. His skin was cool to touch and his pulse was absent and his pupils dilated, therefore I did not commence CPR (Cardio Pulmonary Resuscitation) and I left the cell”. (Exhibit C.9a, p2).

5.8 An ambulance arrived at about 8.30a.m. and the officers were shown to the cell.

Ambulance Officer Neil Boots said that he was unable to find a pulse, and found rigor mortis had already set in in the left arm. The carotid pulse was also absent, the pupils were fixed and dilated and there was no response. He also noticed lividity in the lower legs. As Mr. Sturt was obviously dead, no further action was taken.

5.9 The police were called immediately, and the first investigator arrived at the unit at 8.49am. Crime Scene Investigators arrived just after 9.00am. and began photographing and examining the scene of death. At 9.36am. the police began interviewing prisoners in the unit and otherwise sorting through the evidence at the scene.

6. Time of death - standard of surveillance 6.1 Dr. Singleton took the core temperature of the body at about 12.15p.m. on 14 January

7. It was 28.6 degrees, or about 9 degrees below normal. Dr. James informed Mrs. Atkins, Counsel Assisting me, that a body would generally lose about 8 degrees

per hour. This suggests that Mr. Sturt’s death occurred at around 2.00a.m. This was accepted by all counsel.

6.2 This time should not be taken as accurate, however, and could be wrong by an hour or so either way, or even more.

6.3 Dr. James said that the appearance of the body was consistent with such an estimate.

He said:- “I noted that the post mortem the following day still revealed prominent fixed livid staining in the lower limbs. This suggests that he had been suspended for a substantial period of time before the body was put in the horizontal position”. (Exhibit C.3a, p3).

6.4 It follows that during at least one or more of the checks made by Officers Bowey and Obst during the evening of the 13th and the morning of the 14th January 1998, Mr.

Sturt was already dead. Neither of them observed him breathing, nor did they observe anything other than his rough body shape. They had no instructions to do more than that, and cannot be criticised having regard to the skill with which the mannequin was constructed. However, I think that they should have been instructed to make a more extensive check.

6.5 The review carried out by Messrs Smedley and Brownjohn on behalf of the Department for Correctional Services recommended:- “That all duty statements for first and second watch officers conducting counts of prisoners be amended to require staff to take reasonable steps to ensure the well-being of all prisoners during the course of the two-hourly count”. (Exhibit C.3a, p3).

7. Recommendations 7.1 I think that the change to duty statements recommended by Messrs Smedley and Brownjohn is appropriate. However, it could be argued that the phrase “reasonable steps” is a little vague. I recommend that the instruction should read:- “That all Duty Statements, for 1st and 2nd Watch Officers conducting counts of prisoners, be amended to require staff to take reasonable steps to ensure the well-being of all prisoners during the course of the two-hourly counts by direct observation of the prisoner’s breathing, or of the prisoner’s skin”.

7.2 Mr. Ey also submitted that I should recommend that “prisoners be given greater access, both in length and amount, of calls to their (legal) representation ... and greater access for prisoners (to) rooms for preparation (of their defence), and as to lengths of stays that legal representatives may have with prisoners ...” (T.44).

7.3 I have no specific evidence that any of the arrangements made by the Department for Correctional Services are inadequate in these matters, only that Mr. Sturt apparently thought they were. It must be remembered that Mr. Sturt was in Port Augusta at his own request, and his lawyer is based in Adelaide.

7.4 I am not satisfied that these factors played a causative role in Mr Sturt’s death. They were not mentioned in any of the letters he wrote in contemplation of death. I am therefore unable to make a recommendation pursuant to Section 25(2) of the Coroners Act.

7.5 Such matters should be addressed at an organisational level. Mr. Ey is a senior practitioner, and if he perceives that problems in these areas exist, then they should be looked into. I suggest that the Law Society of South Australia and the Department for Correctional Services should attempt to resolve these issues by dialogue, if they have not done so already.

Key Words: death in custody; hanging; suicide risk In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 28th day of November, 2000.

……………………………..……… Coroner Inq.No.41/2000