Coroner's Finding: FORSAITH Renald Lance

CORONERS ACT, 2003 SOUTH AUSTRALIA FINDING OF INQUEST An Inquest taken on behalf of our Sovereign Lady the Queen at Adelaide in the State of South Australia, on the 29th and 30th days of January 2008 and the 6th day of June 2008, by the Coroner’s Court of the said State, constituted of Mark Frederick Johns, State Coroner, into the death of Renald Lance Forsaith.

The said Court finds that Renald Lance Forsaith aged 51 years, late of Yatala Labour Prison, 1 Peter Brown Drive, Northfield died at Yatala Labour Prison, 1 Peter Brown Drive, Northfield, South Australia on the 6th day of April 2005 as a result of neck compression due to hanging. The said Court finds that the circumstances of his death were as follows:

1. Introduction and background 1.1. Mr Renald Lance Forsaith was 51 years of age at the date of his death in Yatala Labour Prison on 6 April 2005. He was being held on remand for a charge of attempted murder, causing grievous bodily harm with intent to do such harm and endangering life. He had been remanded in custody since 27 June 2004 when he had been arrested for these offences. The victim of the alleged offending was Mr Forsaith’s female housemate and friend, Daniela Janz.

1.2. The allegations by Ms Janz were that Mr Forsaith assaulted her violently and attempted to strangle her several times to the point where she passed out.

Mr Forsaith’s account of the period during which the offending was alleged to have occurred was that he could not remember anything. It was clear though that he had been consuming illicit drugs and was heavily intoxicated with amphetamines at the time. A number of notes were retrieved by police officers from the premises in which

the alleged offending occurred and at which Mr Forsaith was later arrested. The notes appear to have been written by him and demonstrated that he was considering selfharm at that time. Accordingly, the police assessed him when he was initially arrested and held in police custody as being a prisoner at risk of self-harm.

2. Mr Forsaith’s incarceration at Yatala Labour Prison 2.1. Upon his entry to Yatala Labour Prison, Mr Forsaith was interviewed and a Prisoner Stress Screening Form was produced as a result of that interview. The information he provided for the purposes of that assessment caused the assessor to consider that he was not at risk of self-harm and the officer completing the form wrote the comment ‘very positive’ in the appropriate place on the form. Mr Forsaith was examined by Mr Peter Beaumont who was the Admission Nurse at Yatala Labour Prison at the relevant time. Mr Beaumont gave evidence at the Inquest. He said he saw Mr Forsaith at approximately 8pm in the evening and that Mr Forsaith presented as being polite, humble and cooperative. He gave a history of anxiety and denied drug use apart from cannabis1. Mr Beaumont said that Mr Forsaith denied having ever been in gaol before. Mr Forsaith was not prepared to allow the prison authorities to contact his general practitioner. Mr Beaumont thought that this was attributable to embarrassment on the part of Mr Forsaith for being in custody and that he did not want his general practitioner to become aware of this. Mr Beaumont generally thought that Mr Forsaith was being honest in his answers to the questions concerning risk of self-harm. Mr Beaumont did not assess Mr Forsaith as being at such risk.

2.2. Mr Beaumont gave evidence of having attended upon Mr Forsaith again on 4 November 2004 when Mr Forsaith was complaining of dizziness. Mr Beaumont thought on that occasion the dizziness was a symptom of anxiety being experienced by Mr Forsaith about his Court case.

2.3. The evidence of the circumstances of Mr Forsaith’s incarceration from July until his death in April the following year reveals no events that could or should have alerted prison authorities to the possibility that he was at risk of self-harm. This is so notwithstanding the notes that had been discovered by police at the time of Mr Forsaith’s arrest. Police reacted appropriately in assessing Mr Forsaith as a prisoner at risk while in their custody having regard to the content of that material.

1 In this Mr Forsaith was clearly being untruthful having regard to his behaviour at the time of the alleged offending, and an extensive history of drug use revealed in other interviews.

However, there was nothing in his subsequent presentation to prison authorities, nor in his behaviour during his relatively lengthy period of remand in custody, that could have reasonably caused prison authorities to consider him to be at risk. I elaborate upon my reasons for that conclusion.

2.4. Ms Pamela Brown was a social worker employed at Yatala Labour Prison during

2004. She gave evidence at the Inquest. She had a number of contacts with Mr Forsaith over the period of his custody at the prison. She first saw him on 30 June 2004 when he was anxious because the previous night his cellmate had pressured him to have sex. This situation was resolved by Mr Forsaith being moved to a different cell and there was no further similar complaint of which Ms Brown or any other witness provided any account. Ms Brown stated that Mr Forsaith was concerned about his personal property which he understood was being sold without his consent by Ms Janz who had possession of his house. Ms Brown had a number of conversations with Mr Forsaith about that matter, and about concerns that Mr Forsaith had about his legal representation and the conduct of his case. However, Ms Brown said that she never thought that Mr Forsaith was at risk of self-harm and he never gave her any reason to think that.

2.5. Despite Mr Forsaith’s reservations about the conduct of his legal affairs, it appears that his solicitor was approaching his case with appropriate diligence. In fact, his solicitor arranged for several psychiatric reports for the purposes of a possible bail application and also for the purposes of assessing Mr Forsaith’s fitness to plead and his mental state at the time of the alleged offending. Opinions were obtained from Dr Craig Raeside, Psychiatrist, Dr Christopher Branson, Psychiatrist and Dr Richard Balfour, Psychiatrist. Each of these practitioners conducted a psychiatric assessment of Mr Forsaith. None of them suggested that he was at risk of self-harm. These assessments were conducted in the period September to November 2004.

2.6. During the period from November 2004 to March 2005 Mr Forsaith was visited by two of his personal friends Mr Stephen Smith and Mr Robert Curnow. Mr Stephen Smith gave evidence at the Inquest that he had known Mr Forsaith since the age of sixteen. He had lost contact with Mr Forsaith for some time but contact was re-established a couple of years before Mr Forsaith was charged with the offences that led to his incarceration. When Mr Forsaith was in gaol Mr Smith and another friend Mr Curnow visited him regularly.

2.7. Mr Smith said that Mr Forsaith had had a significant history of using intravenous drugs. He had seen Mr Forsaith two days before his arrest and thought that he was severely affected by drugs at that time. He was very confused. When Mr Smith next saw him in November 2004, it was at Yatala Labour Prison and Mr Smith thought that Mr Forsaith seemed much better. His view was that Mr Forsaith’s forcible abstention from drugs during his incarceration had done him ‘a world of good’2. Mr Forsaith was denying that he had done anything wrong in relation to Ms Janz but was trying to maintain a positive disposition. Mr Smith did not consider that Mr Forsaith, despite his frustration at the progress of his Court case, was thinking about self-harm.

However, Mr Smith did say that by reason of his knowledge of Mr Forsaith over a period of years he was not surprised when Mr Forsaith committed suicide3. Mr Smith said that Mr Forsaith was always ‘on the edge’ and that his brother had committed suicide when Mr Forsaith was in his teens4. Mr Smith said of the family that they were always ‘on the edge’5 as a family and that is why he was not particularly surprised by Mr Forsaith’s suicide. But Mr Forsaith never said anything specific during any visit that gave Mr Smith particular cause for concern.

2.8. In fact Mr Forsaith did have a significant history of depression as revealed by notes of admissions to Glenside Campus for depressive episodes in the 1980s6. An assessment by Consultant Psychiatrist Dr D Kelly on 16 February 1987 noted that he had admitted himself with an acute onset of depressive symptoms. He was discharged the following day with a diagnosis of personality disorder with narcissistic and anti-social traits, adjustment disorder with depressed mood and alcohol abuse. This diagnosis is consistent with the assessments made by the psychiatrists who saw Mr Forsaith in Yatala Labour Prison in the latter half of 2004.

2.9. Conclusion In summary I find that Mr Forsaith showed no sign of being at risk of self-harm during his incarceration at Yatala Labour Prison.

2 Transcript, page 58 3 Transcript, page 59 4 Transcript, page 62 5 Transcript, page 62 6 Exhibit C33z

3. Circumstances surrounding the discovery of Mr Forsaith on 5 April 2005 3.1. Correctional Officer Jason Newell gave evidence at the Inquest. He was on duty at Yatala Labour Prison from 11pm until 7:30am on the night of 5/6 April 2005. He gave evidence of having conducted regular two hourly patrols throughout the night including inspections of Mr Forsaith’s cell, number 305. He said that he noted at the patrol conducted at 3am that Mr Forsaith was in his cell with the television turned on and appeared to be either asleep or awake but certainly alive on his bunk at that time7.

However, at the patrol conducted at 5am, Mr Newell noted that Mr Forsaith was not lying on his bunk. Instead he appeared to be in a standing position8. Mr Newell turned the cell light on from the external switch and then could see that Mr Forsaith was hanging from something which was tied to the top of the shelf near his bed. Mr Newell concluded that Mr Forsaith had hanged himself and called a ‘Code Black’ which is an alarm call to alert other officers to an emergency. Other officers attended and the ligature suspending Mr Forsaith was cut. Mr Forsaith was then placed on the cell floor and cardiopulmonary resuscitation was administered. Prison infirmary staff attended as did the Officer in Charge of the prison and a number of other prison officers. The Officer in Charge of the prison, Douglas Farr, gave evidence which was consistent with that of Mr Newell.

4. Conclusions and Recommendation 4.1. I find that appropriate procedures were followed by Mr Newell, Mr Farr and other relevant prison staff in response to the situation with which they were presented.

4.2. I find that Mr Forsaith’s death by suicide could not have been foreseen by prison authorities having regard to his behaviour during the period of his incarceration.

Mr Forsaith suspended himself from the structure supporting the shelf in his prison cell. This very structure or its equivalent in other cells has been used by other prisoners for the same purpose. I refer to previous recommendations in relation to the removal of hanging points from prisons. A letter from Mr Peter Severin, Chief Executive of the Department for Correctional Services dated 21 January 2008 was provided to the Court. It was received and admitted as Exhibit C32b. It refers to various projects which have been undertaken by the Department with a view to improving the safety of prison cells. Unfortunately, the fact remains that the issue of 7 Transcript, page 71 8 Transcript, page 74

hanging points remains to be properly addressed at Yatala Labour Prison. Similar bookshelves continue to exist in the prison today and the problem has not been eliminated. I can do no more than refer to previous recommendations and indicate that I endorse them and adopt them for the purposes of this Finding.

Key Words: Death in custody; Hanging; Prisons; Suicide In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 6th day of June, 2008.

State Coroner Inquest Number 2/2008 (0979/05)