Coroner's Finding: DEWSON Brian Keith

CORONERS ACT, 1975 AS AMENDED SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Port Augusta in the State of South Australia, on the 19th, 20th, 21st and 22nd days of January 2004 and the 13th day of February 2004, before Wayne Cromwell Chivell, a Coroner for the said State, concerning the death of Brian Keith Dewson.

I, the said Coroner, find that, Brian Keith Dewson aged 33 years, late of Port Augusta Prison, Highway One, Port Augusta, South Australia died at Port Augusta, South Australia on the 5th day of November 2000 as a result of hanging.

1. Reason for Inquest 1.1. Brian Dewson was taken into custody on 5 October 2000, when he was remanded to appear in the Whyalla Magistrates Court on 10 October 2000 on charges of assault on a member of his own family contrary to Section 39(1) of the Criminal Law Consolidation Act 1935, and failing to comply with a restraining order contrary to Section 99I(1) of the Summary Procedure Act 1921. On 10 October 2000 he was sentenced by Mr M E Frederick SM to imprisonment for a period of 2 years with a non parole period of 11 months.

1.2. Accordingly, at the time of his death on 5 November 2000 at the Port Augusta Prison (PAP), Mr Dewson was ‘detained in custody within the State pursuant to an Act or law of the State’ within the meaning of Section 12(1)(da) of the Coroner's Act, and an inquest was therefore mandatory pursuant to Section 14(1a) of that Act.

2. Introduction 2.1. At about 8:08pm on 5 November 2000, Correctional Services Officer (CSO) Mary Doherty was performing a medication round with Registered Nurse Antonie Pugh and CSO David Casserley in the Spinifex Unit at PAP.

2.2. The three people entered the Unit at approximate 8:03pm and CSO Doherty escorted RN Pugh while CSO Casserley undertook the count of prisoners in the Unit.

2.3. After they completed the section known as Spinifex 3, they moved to Spinifex 4.

CSO Casserley undertook the count in H Wing and RN Pugh and CSO Doherty moved to G Wing and went to cell G6 occupied by Brian Dewson. Mr Dewson was the only prisoner in G Wing who required medication. CSO Doherty’s statement records what occurred as follows: 'I dropped the trap and called out to Prisoner Dewson stating “Brian medication”, there was no response. I called out to him again and again there was no reply. His cell was in complete darkness so I shone the torch through the trap and saw Prisoner Dewson hanging from a sheet tied to the top rung of the bench in his cell. The sheet was taut and appeared to be supporting his upper body. He was in a kneeling position with the bottom half of his legs facing towards the back of the cell and his upper body leaning forward. His head was facing towards the cell door and was directly level with the height of the trap on the cell door. His left shoulder was facing slightly to his left and his arms were draped down along the side of his body, with his knuckles touching the ground and his finger curled slightly under. His body was extremely pale and his face had a slightly reddish/purplish tinge. The only clothing he was wearing was a pair of prisoner issue jeans and a pair of blue thongs.

I immediately called Code Black Spinifex twice and asked for a master key to be brought to the unit over the radio. I then called for a Priority One Ambulance for Spinifex. I then ran to the office and grabbed the Hoffman knife and returned to cell G6 where Officer Casserley and Medic Tony Pugh were waiting. I then ran to the Spinifex door and waited for other officers to arrive with the master key. Officers Trevor Barry, Craig Bowshire and Officer in Charge Arnold Neyman arrived in a vehicle at approximately 2010 hours. Officer Bowshire slid the key along the ground to me and I unmastered the cell.

Tony Pugh and Officer Casserley entered the cell and Tony Pugh supported Prisoner Dewson while Officer Casserley cut the sheet and lowered Prisoner Dewson to the ground. I then ran to the office and grabbed the Air Viva and ran back to cell G6 and Officer Casserley and Medic Pugh started to attempt resuscitation.

I then heard the siren of the ambulance so I ran to the door of Spinifex and directed the ambulance officers to cell G6. Prisoner Dewson was declared life extinct by Paramedic Duncan Johnstone at 2030 hours.' (Exhibit C19, pp2-4)

2.4. RN Pugh said that he noted the time at which CSO Doherty called the Code Black as 8:08pm (see his statement Exhibit C23, p2-3). This time was also noted by CSO Bowshire who was in the control room at that time (see his statement Exhibit C20, p1).

2.5. CSOs Bowshire, Barry and Neyman conveyed the master key to G Wing by driving the 200 metres or so in a departmental vehicle. They arrived in the wing at approximately 8:10pm, or two minutes after the Code Black was called.

2.6. RN Pugh described his observations of Mr Dewson as follows: 'I went inside where I saw a male person known to me as Brian Dewson who had a piece of bed sheet that was made into a tie around his neck and was secured around the steel pipe that forms a frame to a shelf within the cell. Dewson was on his knees leaning facing towards the cell door on a bit of an angle. He was wearing jeans I think and I can’t recall what else. I immediately supported Brian by holding under the arm pits whilst one of the other officers cut the tie around his neck. I then let Dewson down on the cell floor on his back where I placed my right hand up under the tie around his neck and it came away very easily. I then looked and felt Brian’s face and it was cold to touch and his facial complexion was a purple colour from congestion of blood around the neck. His pupils were fixed and dilated and I was unable to find a radial or jugular pulse and there was no respiration. The other officers and I then commenced to perform CPR on Dewson and I was performing external cardiac massage whilst one other officer was performing ventilation. We continued this and periodically checked Dewson for a pulse or respiration but were unable to locate any pulse or respiration. CPR was continued until the ambulance arrived at about 8:20pm.' (Exhibit C23, p3)

2.7. RN Pugh told me that he did not untie a knot when he removed the sheet from around Mr Dewson’s neck (T179).

2.8. An examination of the photographs taken by the police investigators reveals that a strip of bedsheet had been fed through a gap between a shelf in Mr Dewson’s cell and a metal tubular bracket installed to support the shelf. The gap was only about 1mm wide. The sheet had been tied around the tube, and then left in a large loop in which Mr Dewson’s head had been suspended. When CSO Casserley cut the sheet, it was no longer fixed around Mr Dewson’s neck.

3. Cause of death 3.1. A post-mortem examination of the body of the deceased was performed by Dr R A James, Chief Forensic Pathologist at the Forensic Science Centre on 8 November

4. Dr James’ diagnosed that the cause of death was ‘hanging’. Dr James described the injury to Mr Dewson’s neck as follows: '2. Noose mark. There was an orange colour abrasion about 2 cm in average diameter across the front of the neck at the level of the thyroid cartilage. It was prominent on the right side of the neck and anteriorly but almost invisible on the left side. There were no asphyxial features on the facial tissues.' (Exhibit C3a, p3)

3.2. Dr James commented: 'In particular there is no particular evidence at post-mortem to suggest the involvement of any person other than the deceased in relation to his death.' (Exhibit C3a, p6)

3.3. Toxicological analysis of Mr Dewson’s blood revealed that it contained a 0.29mg/L of citalopram (Cipramil) which was described as a non-toxic/therapeutic level, and 0.22mg/L of doxylamine (Restavit) which was also described as non-toxic/therapeutic (see the statement of Mr D C Vozzo, Senior Forensic Scientist, Exhibit C4a). Mr Vozzo commented that there was no chlorpromazine or any other common drugs including alcohol detected in the blood.

3.4. I accept the evidence of Dr James and find that the cause of Mr Dewson’s death was hanging.

4. Background 4.1. According to a report prepared by Mr Mark Holmes, Senior Psychologist, in March 2000, Mr Dewson was born on 25 March 1967 in Wittenoom in the north-west of Western Australia. He described both his father and mother as alcoholics, and said that his childhood was characterised by living on the streets from the age of about 12 or 13, surviving by petty crime. He said that he was sexually assaulted by a man in whose foster care he had been placed at the age of 14. He said that he was expelled from Year 7 in primary school twice, and once in first year high school. He was placed in a special class for slow learners and admitted being violent towards teachers. He began using drugs at school (see Exhibit C18d).

4.2. Mr Dewson said that he began using cannabis at the age of 10 and had used cannabis regularly ever since at the rate of up to ten bongs per day. He also began using LSD at the age of 16, as well as amphetamines which he took intravenously. He also

began using heroin at the age of 16 and that he had used it ‘on and off’ ever since, acquiring a habit costing $150 to $200 per day at times. He had also been addicted to morphine and pethidine, and had used cocaine, magic mushrooms and Datura, serapax, Valium, rohypnol and murilex. He said that he had also abused alcohol since the age of 10, to the extent that at one stage he was drinking methylated spirits.

He had experienced delirium tremens in the past when withdrawing from alcohol (ibid).

4.3. Mr Dewson had committed many offences over the years, mainly of a relatively minor nature and usually when under the influence of drugs or alcohol. Mr Dewson told Mr Holmes that he was frequently angry and aggressive. Mr Holmes noted: 'Regarding anger management, the pattern of responses suggests considerable problems with temper and aggressive behaviour. Mr Dewson’s responses suggest that he is an individual who is easily angered, has difficulty controlling the expression of his anger, and is perceived by others as having a hostile, angry temperament. When he loses control of his anger, he is likely to respond with more extreme displays of anger, including damage to property and threats to assault others. However, some of these displays may be sudden and unexpected, as he may not display his anger readily when it is experienced. It is likely that his potentially explosive temper and the potential for physical violence intimidate those around him.

With respect to suicidal ideation. Mr Dewson is not reporting being disturbed by thoughts of self-harm.' (Exhibit C18d, p11)

4.4. Mr Dewson was married to Christine Dewson and was the father of twin boys who were born in December 1998. Their relationship was troubled with multiple instances of domestic violence perpetrated by Mr Dewson on his wife.

4.5. While they were living in Cowell, Mr Dewson consulted Dr Alexander Ochnik, who described Mr Dewson as ‘a self-centered person with fairly marked and obviously depressive tendencies and generally a very unhappy and angry person’ (see Exhibit 15a, p1).

5. Recent offending and treatment 5.1. Dr Ochnik’s casenotes (Exhibit C15b) record that he saw Mr Dewson on 31 December 1998. Mr Dewson told him that he was facing a court case and that he had been on antidepressants for six or seven weeks.

5.2. Mrs Dewson alleged that on one occasion in 1999 (she was very vague as to the date, see T16-18), Mr Dewson attained Serapax from Dr Ochnik despite the fact that she visited Dr Ochnik that day and told him that Mr Dewson had told her that he would use them to overdose. She said that Dr Ochnik’s response was: 'if Brian wants pills I’ll prescribe him whatever he wants and he said if he commits suicide you are not to blame.' (T17)

5.3. Dr Ochnik’s records do not contain any reference to the prescription of Serapax. In a letter from his solicitors dated 15 January 2004, it was asserted that Dr Ochnick had ‘no independent memory of the deceased’.

5.4. Mrs Dewson was perturbed about this incident because she alleged that later that evening her husband tried to choke her after taking Serapax and drinking methylated spirits (T17).

5.5. Having regard to the remoteness of this event from the events of November 2000, particularly having regard to Dr O’Brien’s becoming involved later in that year, I do not consider it necessary to resolve this conflict on the evidence. Even if Dr Ochnik did what Mrs Dewson alleges, I think that it is unlikely to have been relevant to the ultimate outcome.

5.6. Mrs Dewson also alleged that she told Constable Adamson, who was then the Officer in Charge of the Cowell Police Station, what had happened that day, and that her husband had told her that he wanted to commit suicide.

5.7. Constable Adamson denied that Mrs Dewson told him anything of the sort. His statement details the many occasions on which he was involved in domestic violence situations between Mr and Mrs Dewson, and yet he said that there was never an occasion that Mrs Dewson told him that her husband was suicidal (Exhibit C17, p2-3).

5.8. For the reasons expressed in paragraph 5.5 above, it is not necessary to resolve this conflict either.

5.9. Mr Dewson appeared in the Whyalla Magistrates Court on 12 January 1999 and he was sentenced for two separate incidents of offending. For offences committed on 4 July 1998 of common assault, damaging property and disorderly behaviour he was sentenced to a term of imprisonment, suspended upon him entering into a bond for a

period of 12 months. For offences of threatening to cause harm and resisting police committed on 7 January 1999, only five days before he appeared in court, he received another sentence of imprisonment suspended upon him entering into a bond for 18 months.

5.10. Mr Dewson was imprisoned for short periods in March, May, June and July of 1999.

He first saw Dr Ken O’Brien, the Clinical Director of the Forensic Mental Health Service, on 8 July 1999 at Port Augusta Gaol. He was referred to Dr O’Brien by RN Pugh on 1 July 1999 and then by Dr Shroff on the same day. Mr Dewson was assessed as a suicide risk, and a ‘Suicide Risk Assessment Care Plan’ was put in place until he could be seen by Dr O’Brien. Dr O’Brien found him to be depressed, angry, hostile and anxious, and prescribed Cipramil.

5.11. On 3 August 1999 Mr Dewson saw Dr Jha, a visiting Psychiatrist at the Whyalla Hospital, at the request of the Court Assessment Service. Dr Jha wrote a report dated 12 August 1999 in which he stated that Mr Dewson’s diagnosis was one of personality disorder of antisocial type, and that he had suffered drug induced psychosis in the past and was still abusing drugs. Dr Jha said that most of his criminal behaviours were emanating from his drug dependence/abuse and personality problems.

5.12. On the next day, 4 August 1999, Mr Dewson saw Dr O’Brien, also at the Whyalla Hospital. Dr O’Brien also thought that Mr Dewson had an antisocial personality disorder with alcohol and polysubstance abuse. Dr O’Brien told me when he gave oral evidence that there is no medication available which is useful to treat an antisocial personality disorder, and that the most a psychiatrist can offer is to treat the co-morbidities including symptoms of depression and anxiety (T133).

5.13. Mr Dewson was remanded in custody on 20 September 1999, and he remained there until 29 October 1999 when he appeared in the Whyalla Magistrates Court again and was sentenced for a number of offences including common assault on a person other than a family member, common assault on a family member (2 counts), resisting police, failing to comply with a restraining order and failing to comply with a bail agreement. He was sentenced to a further period of imprisonment, suspended upon him entering into a bond to be of good behaviour for a further 18 months.

5.14. When he was remanded in custody on 20 September 1999, RN Pugh noted that Mr Dewson was suicidal. For that reason, he was transferred to the infirmary where he remained until 23 September 1999 when he was transferred to the Adelaide Remand Centre. On 7 October 1999 Mr Dewson was transferred to James Nash House, the inpatient psychiatric facility operated by the Forensic Mental Health Service. He remained at James Nash House until 12 October 1999 when he was discharged.

5.15. Mr Dewson did not comply with the terms of the bond imposed on 29 October 1999 in that he failed to report to the Community Corrections Centre on the arranged date.

He finally reported on 30 November 1999. On 19 January 2000, Mrs Dewson told Ms Alison McAlister, his supervising Community Corrections Officer, that Mr Dewson had returned to Western Australia ‘for good’.

5.16. On 7 February 2000 Mr Dewson rang Ms McAlister and told her that he had returned to South Australia. On 13 February 2000 he attended at the Cowell Hospital complaining of feeling sick. He was seen by Dr Ochnik on 14 February 2000. Dr Ochnik described him as ‘extremely ill and very toxic, suffering from Alcoholic Hepatitis and exacerbation of Hepatitis C'. He told Dr Ochnik that he had been using heroin in Western Australia, and that he thought he also had Ross River virus. Dr Ochnik admitted him to the hospital where he remained until 17 February 2000 when he was discharged and advised ‘very strongly’ not to use drugs or alcohol (see Exhibit C15a, p3).

5.17. On 1 March 2000 Mr Dewson assaulted his wife again and breached the domestic violence restraining order. He was remanded in custody on 2 March 2000 and he remained there until 7 March 2000 when he appeared in the Port Augusta Magistrates Court and was sentenced to six days imprisonment, backdated to 2 March 2000.

5.18. The Psychologist Mr Mark Holmes saw Mr Dewson on 18 February and 16 March 2000 at the request of Community Corrections Officers McAlister and Bassi. Mr Holmes wrote a report dated 29 March 2000 which provides a particularly thorough and helpful assessment of Mr Dewson’s situation (see Exhibit C18d). Mr Holmes took a very thorough history dealing with particular topics such as family, eduction, employment, relationships, interpersonal dealings, medical, mental health, anger, depression/suicidal ideation, anxiety, drug and alcohol, financial and criminal history.

Mr Holmes performed a number of psychological tests and described Mr Dewson’s clinical features in detail. He expressed his opinions as follows:

'CLINICAL OPTIONS In summary, Mr Dewson was born into a dysfunctional and chaotic family. His parents were both chronic abusers of alcohol who neglected their children and were repeatedly physically violent toward each other. Due to parental neglect, he and his siblings were forced into foster care on numerous occasions culminating in Mr Dewson being sexually abused on one occasion. Mr Dewson spent a number of years living on the streets and survived by abusing and dealing in drugs as well as performing acts of crime. Mr Dewson was extremely violent and a bully while at school. He used stand-over tactics with other children and threw chairs at teachers, leading him to be suspended twice during year 7 in primary school. He was a class clown who appears to have possessed a specific learning deficit when presented with large amounts of information. His friends from school all appear to have been a negative influence on Mr Dewson with most of this peer group either now deceased from drug-induced accidents or spending considerable periods incarcerated for drug possession/dealing.

He has an impoverished work history which appears to be suggestive of a man with little formal employment, due to his propensity for dealing in drugs and financing his considerable drug habit in this area, as he duly admits. His current work goals involve participating in a field of employment that is likely to bring him into contact with alcoholic beverages. His relationship and interpersonal history appears to have been focused on the drug culture and there appears to be strong indicators of current domestic violence in his marital relationship. His medical history is characterised by lifethreatening drug-induced overdoses as well as blackouts, losses of consciousness and seizures through abusing drugs. He possesses Hepatitis C antibodies.

He has an extremely high potential for aggression, particularly within the context of abusing drugs and/or alcohol. He indicates a low frustration tolerance for many everyday problems and this likely precipitates his violent confrontations with his wife. He has an extensive drug-taking history and appears to have become dependent upon various substances at various times. His criminal history involves a mixture of offences for drug-related crime as well as efforts to escape police apprehension or custodial conditions demonstrating his irresponsibility. In addition, his propensity for violent conduct appears to include both family members and other members of the community.

He appears to show relatively little remorse for his actions and views incarceration as an opportunity to become free of drugs for a while before continuing his chaotic lifestyle.

Results of the clinical personality instrument indicate that he is an individual who tends to exaggerate his current problems and present himself in a negative light. This appears to have been a poor attempt to minimise his responsibility for his current problems and is associated with his Axis 2 diagnosis below. Despite this tendency, his cognitive and neuropsychological functioning showed no significant evidence for any cognitive impairment at this time. I would anticipate that with future abuse Mr Dewson’s condition will deteriorate and he will begin to show signs of cognitive decline in one or more areas.

In my clinical opinion, taking into account Mr Dewson’s clinical interview, background history and the results of psychological testing, I believe he possesses the following diagnoses: Axis 1: 303.90 Alcohol Dependence Axis 2: 301.7 Antisocial Personality Disorder.

The essential features of an antisocial personality disorder is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years as indicating by the following: (1) Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest; (2) Impulsivity or failure to plan ahead; (3) Irritability and aggressiveness, as indicated by repeated physical fights or assaults; (4) Reckless disregard for the safety of self or others; (5) Consistent irresponsibility as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations; (6) Lack of remorse as indicated by being indifferent to or rationalising having hurt, mistreated or stolen from another.

They may display a glib, superficial charm. They may be irresponsible and exploitative in their sexual relationships. Individuals with this condition typically display little or only surface-level changes to their behaviour until the 4th decade of life. In Mr Dewson’s case, this disorder does not appear to be remitting substantially at this time.

Despite his condition being relatively difficult to influence, his living circumstances necessitate the need for some intervention.

RECOMMENDATIONS (1) When suitable, that Mr Dewson attends an Anger Management Programme to increase his resistance to act in an impulsive, reactive and aggressive manner.

(2) That Mr Dewson attends an Alcohol and Other Drugs Programme to reduce his likelihood of abusing alcohol and other drugs.

(3) That any courses that Mr Dewson attends take into account his virtually illiterate condition. This difficulty should also be taken into account with his case management. To this end, material should be presented sparingly in written form and verbal material should be re-iterated and presented in small, manageable amounts so that Mr Dewson’s understanding will be facilitated. To ensure that Mr Dewson understands what is required of him, he should be asked to repeat instructions so that full insight is reached.

(4) That Mr Dewson attends a literacy and numeracy course to assist him in developing better skills for independent living.' (Exhibit C18d, p12-14)

5.19. On 12 April 2000 Mr Dewson committed a further assault on his wife and breach of restraining order, as a result of which he appeared in the Port Pirie Magistrates Court on 4 July 2000. He was sentenced to three months imprisonment with an order pursuant to Section 38 of the Criminal Law (Sentencing) Act that he be released before serving the whole sentence, upon entering into a bond suspending the balance of the sentence. As a result of this order he remained in prison until 17 July 2000.

5.20. On 2 August 2000 Mr Dewson was remanded in custody on a charge of common assault on a person other than a family member, the offence having occurred on 1 August 2000. He remained in custody until he appeared in the Port Pirie Magistrates Court on 11 September 2000 when he was sentenced to four weeks imprisonment, commencing 6 August 2000.

5.21. During this period of imprisonment, Mr Dewson was seen by Dr Mattner, who also assessed him as a suicide risk and a further Suicide Risk Assessment Care Plan was issued on 4 September 2000. Mr Dewson saw Dr Nambiar, a colleague of Dr O’Brien, on 11 September 2000 and he confirmed that Mr Dewson represented a suicide risk. Mr Dewson was discharged from prison the next day on 12 September 2000.

5.22. On 26 September 2000 Mr Dewson committed further offences consisting of common assault upon his wife and failing to comply with a restraining order, as a result of which he was remanded in custody until 3 October 2000 when he was released on bail. He was back in custody again on 5 October 2000, and he remained there until 10 October 2000. On that day, he was sentenced to two years in prison with a non-parole period of 11 months as previously outlined.

5.23. On 19 October 2000 Dr O’Brien saw Mr Dewson again, and described him as angry and showing signs of chronic depression. Mr Dewson complained that he did not like taking chlorpromazine, and so Dr O’Brien prescribed sodium valproate as a mood stabiliser and sedative. He said that depending on Mr Dewson’s response to sodium valproate, he proposed to taper the chlorpromazine. He considered referring Mr Dewson to Mr David Curnow, another Psychologist employed by the Department for Correctional Services, for anger management counselling, however he decided to leave that referral until his next visit when he could check Mr Dewson’s response to the sodium valproate.

5.24. On 24 October 2000, RN Jordan telephoned Dr O’Brien and advised that Mr Dewson was complaining of nausea. The sodium valproate was ceased and Dr O’Brien requested that Mr Dewson be referred to Mr Curnow for assessment. Unfortunately, Mr Dewson’s death took place before that referral was made.

5.25. On 28 and 30 October 2000 Mr Dewson was seen by RN Wedding, complaining of insomnia. He was given ‘Restavit’, a mild sedative, and was placed on the list to see Dr Nambiar who was due to visit PAP on 6 November 2000.

6. Issues Arising at Inquest 6.1. Indications of suicidal intention I have already mentioned that on at least two occasions in the previous twelve months, Mr Dewson had been the subject of a Suicide Risk Assessment Care Plan being undertaken at PAP. The last of these had occurred in September 2000. Since that time, Mr Dewson had seen Dr Nambiar and also Dr O’Brien and had his medication changed.

6.2. Dr O’Brien told me that he did not consider that Mr Dewson was particularly at risk of suicide when he saw him on 19 October 2000, although a person with an antisocial personality disorder presents a chronic risk of suicide (T151).

6.3. In particular, Dr O’Brien said that although Mr Dewson seemed angry when he saw him on 19 October 2000, he was not particularly concerned about the risk of self-harm. Having regard to his history, had Mr Dewson presented such a risk Dr O’Brien had a range of options available, from advising the nurses right through to detention pursuant to the Mental Health Act and transferral to James Nash House.

(T150-152).

6.4. There is no evidence before me that Mr Dewson expressed any particular distress or suicidal ideation at any time during the period of imprisonment which commenced on 5 October 2000.

6.5. About a week before Mr Dewson died, RN Pugh said that he spoke to him after he had been transferred to the Spinifex Unit, which is outside the walls of the prison. He

said that Mr Dewson ‘appeared cheerful and said that it was much better out here’ (Exhibit C23, p4). He commented: 'On the basis of this conversation, I thought he was doing alright and was happy enough to be where he was. I was very surprised to find Brian in the situation that resulted in the loss of his life.' (Exhibit C23, p4)

6.6. On 3 November 2000, Mr Dewson telephoned his wife at 7:21pm. The conversation was recorded. Mr and Mrs Dewson discussed the subject of divorce, and the fact that she had already contacted a lawyer. Mr Dewson’s principal concern appeared to have been whether he could continue to see the children (the transcript of this conversation forms part of Exhibit C13g).

6.7. On 4 November 2000, Mr Dewson approached CSO Darren Fox and asked him to arrange a further telephone call on the basis that he was having ‘family trouble’. CSO Fox facilitated the call which took place at 8:28am and lasted 9 minutes and 28 seconds. This call was also recorded. Again the subject of divorce was discussed.

Mr Dewson indicated that he did not want a divorce, although he would cooperate if she wished to proceed. Mrs Dewson promised to bring the boys to see him, and he asked her to send him a card because he said: 'Cause I’m not, I’m here all alone you know, people don’t understand that, I’m alone you know what I mean…..and it hurts mate.' (Exhibit C13g, p14)

6.8. CSO Fox said that Mr Dewson thanked him afterwards for arranging the telephone call, and did not think that Mr Dewson was upset or otherwise distressed at that time

(T185).

6.9. Mr Adam Whittington, another prisoner, told the police investigators that Mr Dewson was upset during his time in prison because his wife would not let him see the children. Mr Whittington added: 'Sometime on either Friday the 3rd of November 2000 or that weekend, someone in the Spinifex unit (Spinifex four) told me that Brian was in his room sometime on Friday making officer assisted calls from within the living area of the unit. I’m not sure where but I was told that either whilst making that call or when he was back in his cell, that he had been assaulted by a another inmate but he did not know what it was over, possibly the officer assisted call. I noticed at this time that Brian had a cut under his left eye on

the cheek about 2-3 cm long. I asked him who assaulted him but he did not want to say and just said that it had been dealt with.' (Exhibit C10a, p2-3)

6.10. CSO Fox told me that Mr Whittington was a person of minimal intelligence and that he doubted the veracity of this story. The photographs taken of Mr Dewson’s face after his death (Exhibit C11b numbers 9, 11, 12) do not support the allegation of an injury. Dr James makes no mention of any injury on Mr Dewson’s face in his report.

Having regard to the fact that Mr Whittington’s evidence is hearsay in any event, I doubt the veracity of this allegation.

6.11. CSO Doherty said that he spoke to Mr Dewson during the afternoon of 5 November 2000 (although it is not entirely clear that she was referring to this date, I think it is implicit in her evidence at T95-96). She said: 'A. He came to the counter to fill out a finance phone form so that he would have money on his phone for the following day. He had just finished a phone call. He was in a very jovial mood. The information that he told me in relation to the phone call was that he had reached an agreement with his wife that they were going to be divorced. He would do his time and when he was discharged they would stay separated and he would attempt to get himself together and if he could then they would try a reconciliation.

Q. When you described him as 'jovial', what do you mean by that. What things did he say or what conduct did he exhibit that made you form that view.

A. Well he was very happy. He said that he'd had a good phone call with his wife. He was happy with the outcome that they had reached. He seemed quite settled in his own mind.' (T95-96)

6.12. There is no record of Mr Dewson having had a telephone call on 5 November 2000, so I think that CSO Doherty may have been confused about that. It seems more likely that Mr Dewson was referring to the 4 November conversation with his wife.

6.13. In any event, CSO Doherty’s observation that Mr Dewson was ‘jovial’ is significant, and the fact that he was planning another phone call the next day suggests that he was not contemplating suicide at that time.

6.14. At about 4:20pm on Sunday 5 November 2000, Mr Stephen Hay, another prisoner said that he spoke to Mr Dewson and described him as ‘his normal self’ (Exhibit C9a, p1).

6.15. CSO Fox told me that at 4:30pm on 5 November 2000, he locked Mr Dewson in his cell for the evening. He said that he noticed nothing out of the ordinary about Mr Dewson’s demeanour although neither man said anything to the other (T186).

6.16. At 6:17pm, CSO Casserley conducted a count of the prisoners in Spinifex 4, including Mr Dewson’s cell. He said: 'All prisoners were sighted and appeared okay' (Exhibit C21, p1)

6.17. Conclusion Taking all of this evidence into consideration, I conclude that there was nothing upon which any of the Correctional Services officers or Prison Medical Service staff should have formed the conclusion that on 5 November 2000 Mr Dewson constituted a particular suicide risk, or that they should have taken particular measures to ensure his safety.

6.18. In that context, it is not even clear on the evidence that Mr Dewson intended to take his own life on that day. The physical evidence suggests that he had supported his weight on his knees, and placed his head through a loop of sheet which he had tied to the shelf frame. This formed a ligature only to the extent that pressure was applied to the anterior part of his neck by his body weight. The sheet was not tight around his neck, as in a noose. It is entirely possible that Mr Dewson did not realise that this would cause him to become quickly unconscious, as a result of which he could not move his position to save himself from strangulation.

6.19. If this was the case, Mr Dewson’s death could be characterised as accidental. Having regard to Mr Dewson’s impulsive and erratic behaviour, it is entirely possible that he was indulging in attention-seeking behaviour without the intention to commit suicide.

6.20. Emergency Measures The evidence established that a Code Black was called immediately upon the discovery of Mr Dewson’s body. The cell was opened within two minutes.

Cardiopulmonary resuscitation was commenced without delay and an ambulance was called immediately and arrived within minutes. Aggressive attempts to resuscitate Mr Dewson were made without success.

6.21. It is apparent on the basis of this evidence that the Correctional Services officers and RN Pugh did everything they could to resuscitate Mr Dewson, and that they responded with professionalism and efficiency. There are no grounds for criticising any of them in relation to this issue.

6.22. I remain concerned about the issue of keeping a master key at a location remote from the building in which prisoners are accommodated. This has been the subject of a number of inquests over the years (Henry 58/93, Wakely 7/95, Goldsmith 6/96, Brady 27/96, Bonney 28/96, Baillie 24/97, McGuire 46/98 and Carter 23/00). Following the inquest into the death of Henry, I made the following recommendation: 'That the Department reconsider the system whereby access to a prisoner's cell may only be gained with a master key kept in the Main Control Room. If no other way can be found by which access can be guaranteed within 3 minutes, the Department should consider installation of electronically operated doors to all cells.'

6.23. I received a variety of responses to this recommendation, none of which I regarded as satisfactory. I remain of the view that it should be feasible to install an electronic system whereby, upon a Code Black being called, Mr Dewson’s cell could have been opened by an operator sitting at the console in the control room. On that basis, cardio-pulmonary resuscitation could have been commenced immediately, rather than two minutes later. I appreciate that two minutes was a commendably quick response to the Code Black, but the remoteness of the master key created this delay and in my opinion such a delay is avoidable. The three minutes mentioned in the above recommendation is the time it takes to asphyxiate. It is all very well to get access to the cell quickly, but the prisoner may have already been hanging for that long or longer. Immediate access would be preferable.

6.24. The evidence in this case suggests that Mr Dewson was already dead by the time the Code Black was called, and so it can not be argued that the delay had an adverse affect on the outcome in this case. However, there may be other similar cases in which a delay of even two minutes can mean the difference between life and death.

In my view, the Department for Correctional Services should again consider the feasibility of installing such an electronic system, and I will recommend accordingly.

6.25. Cell Design The investigation by Messrs Smedley and Leggatt of the Department for Correctional Services was commendably thorough and prompt. They identified that, in addition to

the 1 millimetre gap between the shelf and the supporting tube, there was a gap of more than 1 centimetre between the rear of the shelf and the wall of the cell which constituted an even more obvious hanging point.

6.26. In their report dated 12 December 2000, Messrs Smedley and Leggatt made the following recommendation: 'That the General Manager of Pt Augusta Prison removes a potential hanging point in the cells in Spinifex and Wattle Units, by modifying the cell shelving to remove the gap between each shelf and the cell wall.' (Exhibit C25)

6.27. The report was forwarded to Mr John Paget, the Chief Executive Officer, and he wrote on the front page: 'Recommendation approved' (Exhibit C25) This endorsement was made on 21 December 2000.

6.28. I was told that the report was then transmitted to the Director, Custodial Services, Ms Eva Leś, for action. I was told that the report was also sent to the Manager, PAP, who submitted a funding request for the necessary corrective work. This request would have been considered by the Works and Equipment Committee of which Ms Leś was a member.

6.29. Notwithstanding these actions, it would appear that no action was taken to comply with the recommendation until 20 October 2003 when Ms Kate Hodder, Counsel Assisting me, contacted Mr Smedley to ascertain whether the recommendation had been implemented.

6.30. As a result of this contact, Mr Smedley alerted the new Chief Executive Officer, Mr Peter Severin, who quickly directed that work should commence immediately to implement the recommendation.

6.31. In the meantime, on the 23 May 2001, Ms Margaret Lindsay died in the Adelaide Women’s Prison as a result of hanging herself from the bookshelf in her cell. An inquest into her death was conducted in 2003, and I handed down a finding on 18 December 2003. On the evidence in that case, if the recommendation made by Messrs Smedley and Leggatt in December 2000 had been implemented more

speedily, Ms Lindsay’s death on 23 May 2001 might have been avoided (see my finding in that case at p26). This is a matter of serious concern.

6.32. I was told by Mr Smedley that Mr Severin has decided to form a new committee, known as the Investigation Review Committee, the function of which will be to monitor the implementation of recommendations made by the Department for Correctional Services investigators, and also recommendations made in this court. I was told that the committee would meet regularly, and would monitor not only the implementation of recommendations which apply to particular prisons, but whether the recommendations are of more general application and should be implemented throughout the prison system in South Australia.

6.33. I was told that 94 out of 190 cells at PAP need the recommended modification in order to remove the hanging points described above. The modification will remove not only the hanging point used by Mr Dewson, but also the gap between the shelf and the wall used by Ms Lindsay, as well as another hanging point on a different shelf used to support the television set in the cell. I was told that 20 cells have been modified so far, and the rest should be completed by the end of February 2004. In the meantime, prisoners considered at risk will not be placed in un-modified cells (T201).

6.34. In the inquest into the death of Ms Lindsay, I referred to the ‘safe-cell’ project being conducted in Victoria. I was informed that the final report of that investigation has yet to be published, but when it is published it’s applicability in South Australia will be the subject of close examination by the Department for Correctional Services.

6.35. In the finding of the inquest into the death of Ms Lindsay, I recommended, among other things: 'The ‘safe-cell’ principles should be adopted and pursued in prisons throughout South Australia as a matter of urgency.' I will make the same recommendation in this case.

6.36. In addition, I was informed that Mr Severin has directed that a much more wideranging examination of techniques to deal with at-risk prisoners will be conducted in order to improve practices in this regard. This approach is to be commended.

7. Recommendations 7.1. I make the following recommendations pursuant to Section 25(2) of the Coroner's Act, 1975:

1. That the Chief Executive Officer, Department for Correctional Services, reconsider the system whereby access to a prisoner’s cell may only be gained with a master key kept in the Main Control Room. In particular, the feasibility of a system whereby the cell could be opened electronically from the Main Control Room should be investigated.

2. The ‘safe-cell’ principles should be adopted and implemented in prisons throughout South Australia as a matter of urgency.

Key Words: Death in Custody; Suicide; Mental/Psychiatric Issues; Cell Design In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 13th day of February, 2004.

Coroner Inquest Number 1/2004 (2868/2000)