Coroner's Finding: Lanzafame, Anthony

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 27th and 28th days of August, the 4th day of September 2020 and the 15th day of December 2021, by the Coroner’s Court of the said State, constituted of Anthony Ernest Schapel, Deputy State Coroner, into the death of Anthony Lanzafame.

The said Court finds that Anthony Lanzafame aged 54 years, late of the Adelaide Remand Centre, 208 Currie Street, Adelaide, South Australia died at Adelaide , South Australia on the 24th day of May 2016 as a result of compression of the neck due to hanging.

The said Court finds that the circumstances of his death were as follows:

1. Introduction, cause of death and reason for inquest 1.1. Anthony Lanzafame was 54 years of age when he died on 24 May 2016. At the time of his death he was a remand prisoner in the Adelaide Remand Centre (the ARC).

1.2. Mr Lanzafame occupied cell 26 in Unit 5 of the ARC. It was in that cell that Mr Lanzafame met his death. I find that Mr Lanzafame died after he hanged himself using a ligature made out of blue material that appeared to have been torn from a bedsheet. The ligature was tied at one end around his neck. The other end was secured to the plumbing associated with the sink in his cell. Mr Lanzafame was located deceased at about 7:20am when correctional officers entered his cell to remove him for the purposes of a court attendance that day. Resuscitative measures were unsuccessful.

Those measures were ceased at 7:52am.

1.3. Mr Lanzafame had been locked down in his cell since he returned from court at about 5:30pm the day before. Mr Lanzafame occupied the cell alone. There was no other person in his cell when it was unlocked and opened the following morning. I find that

no other person was involved in the death of Mr Lanzafame. I find that Mr Lanzafame intentionally took his own life.

1.4. A post-mortem examination was conducted in respect of Mr Lanzafame’s remains by Dr Neil Langlois who is a forensic pathologist at Forensic Science South Australia.

Dr Langlois’ post-mortem report1 was tendered to the inquest. Dr Langlois had inspected the scene at the ARC at about 9:55am on the morning of Mr Lanzafame’s death. Dr Langlois estimated that Mr Lanzafame’s death had occurred at about 7am which was approximately 20 minutes before he was discovered deceased. I will add here that the last patrol conducted of Unit 5 at approximately 5:55am had not revealed anything untoward in Mr Lanzafame’s cell.

1.5. The salient anatomical features noted during Dr Langlois’ autopsy of Mr Lanzafame were a ligature mark around his neck, a fracture of the left superior horn of the thyroid cartilage with associated haemorrhage and superficial incised wounds at the radial aspect of the flexor surface of the left wrist with no underlying vascular damage.

Dr Langlois had noticed within Mr Lanzafame’s cell a safety razor that exhibited evidence of blood staining. The left wrist injury was superficial only and did not contribute to Mr Lanzafame’s death.

1.6. In his report Dr Langlois expresses the opinion that Mr Lanzafame’s cause of death was compression of the neck in keeping with hanging. Dr Langlois explains the mechanism involved is death by way of hanging. It may involve a number of features including obstruction of the veins that drain blood from the head resulting in congestion within the head and reduced blood flow to the brain, compression and obstruction of the arteries of the neck and compression and obstruction of the airway. Dr Langlois explains that when a brain is deprived of blood, loss of consciousness will rapidly occur.

The continued lack of blood supply will cause irreversible damage to the brain after four to five minutes.

1.7. Although Dr Langlois has expressed the opinion that the compression of the neck was ‘in keeping with’ hanging, to my mind there is no doubt that the fatal compression of Mr Lanzafame’s neck in fact resulted from a hanging that had involved the fixation of 1 Exhibit C2a

the ligature to the neck. Accordingly, I find that the cause of Mr Lanzafame’s death was compression of the neck due to hanging.

1.8. Two nicotine patches were on Mr Lanzafame’s body. They were on the right upper chest and the left upper chest respectively. The patches constituted nicotine replacement therapy due to enforced abstinence from smoking following the ARC’s recently imposed anti-smoking policy. Post-mortem toxicology revealed that olanzapine and mirtazapine were found in therapeutic concentrations in a post-mortem blood sample. Olanzapine is an anti-psychotic. Mirtazapine is a drug primarily used to treat depression complicated by anxiety or insomnia. These medications had been prescribed for Mr Lanzafame. There was also nicotine in his blood stream, no doubt from the two nicotine patches.

1.9. Mr Lanzafame’s death was a death in custody in respect of which a mandatory inquest was necessary pursuant to the provisions of the Coroners Act 2003. These are the findings of that inquest.

2. Background 2.1. On 14 December 2014, Mr Lanzafame had been arrested by police and had been charged with the murder of his partner’s son, Andrew Tilbrook. He had been remanded in custody on 15 December 2014 and was admitted to the ARC that day. He remained in custody at the ARC until his death. I understand the only charge that was pending with respect to Mr Lanzafame was the charge of murder. There was no other reason for his custody. He was not a sentenced prisoner at any stage during the currency of his remand in custody for alleged murder. A number of the witness statements upon which the prosecution of Mr Lanzafame for murder would rely, were tendered to the inquest.2 A perusal of those statements leads one to the conclusion that at the time of his death, Mr Lanzafame would have had a realistic expectation that he would be sentenced to a term of imprisonment either for murder or manslaughter depending on the outcome of his trial.

2.2. In fact at the time of his death, Mr Lanzafame was being tried in the Supreme Court on the charge of murder. The trial had not concluded. Mr Lanzafame was contesting that charge but had indicated that he was prepared to plead guilty to manslaughter. This 2 Exhibit C40

intimation had been rejected by prosecuting authorities. That Mr Lanzafame had caused Tilbrook’s death by stabbing did not appear to be in dispute. It seems inevitable, therefore, that Mr Lanzafame would have been at least found guilty of manslaughter which of itself would have attracted a term of imprisonment. None of this would have been lost on Mr Lanzafame.

2.3. Mr Lanzafame left a note in his cell. The note said, ‘SORRY ANGELA SORRY ADELAIDE I WANT A SMOKE FORGIVE ME ANDREW’.3 Angela was Mr Lanzafame’s daughter. Andrew is the deceased, Andrew Tilbrook. It seems that Mr Lanzafame was craving a cigarette despite the nicotine patches.

2.4. It is worthwhile observing from the evidence that had already been led or would be led at his trial, that Mr Lanzafame was a highly strung individual who had a significant alcohol problem. He stabbed Andrew Tilbrook to death in what appears to have been an episode of alcohol fuelled rage. He also had a smoking addiction, said in one report to have involved him having smoked 60 cigarettes a day for in excess of 40 years.

Needless to say, Mr Lanzafame was not permitted to drink alcohol during the course of his period on remand. As far as smoking was concerned, he was at first permitted to smoke in the ARC. However, on 29 May 2015 while Mr Lanzafame was still in custody, the South Australian Government announced that the ARC was going to be South Australia’s first smoke free correctional institution. Smoking would be banned from March 2016. This policy was said to have been developed in order to promote a healthy and safe environment for staff, prisoners and visitors. All staff and prisoners were provided with an information sheet on the day of that announcement.

2.5. The ban on smoking at the ARC commenced on 1 March 2016. Other correctional institutions in South Australia had yet to impose that ban. Unsurprisingly there had been a number of requests by persons on remand in the ARC for transfer to other correctional institutions, for example the Yatala Labour Prison, where smoking was still allowed. It seems that Mr Lanzafame had made such a request and it had been denied. He was still in the ARC at the time the smoking ban came into effect and he would remain there. He would meet his death in May of that year. At some point between the smoking ban announcement and its institution, Mr Lanzafame made an effort to quit smoking. During that transitional period support and counselling to quit 3 Exhibit C29d

smoking were offered. This was provided by persons known as smoke free mentors.

Mr Lanzafame was also provided with nicotine replacement therapy patches. Such was Mr Lanzafame’s apparent addiction to smoking that he would wear a number of patches significantly in excess of what was recommended. He was also detected hoarding patches in his cell which resulted in minor chastisement for him. It may well be that Mr Lanzafame had resigned himself to spending a significant time in prison and therefore in a smoke free environment. It appears that smoking had formed a significant part of Mr Lanzafame’s life.

2.6. Mr Lanzafame’s trial commenced on 16 May 2016 and continued on 17 and 18 May

2016. On 18 May 2016 a mistrial was declared by the trial Judge and the jury was discharged. On the same day a new jury was empanelled and the trial recommenced.

The trial was adjourned for the weekend of 21 and 22 May 2016 and resumed on Monday 23 May 2016. On that day Mr Lanzafame’s former partner, being the mother of the person whom he was accused of having murdered, was due to give evidence. For one reason or another this did not take place as scheduled. However, that day a friend and neighbour of Mr Lanzafame’s partner, whose witness statement I have read, gave evidence against Mr Lanzafame. If her evidence accorded with her witness statement, it would have been compelling in relation to Mr Lanzafame’s intent when he stabbed Andrew Tilbrook. In addition, an audio recording that had been made by another witness at Andrew Tilbrook’s stabbing was also played to the jury. The transcript of that recording was tendered to this inquest. It tends to demonstrate that, shortly before the stabbing, Mr Lanzafame had threatened to kill Andrew Tilbrook, a circumstance that Mr Lanzafame no doubt realised would not help his prospects of avoiding a murder conviction. Indeed, the prosecutor at Mr Lanzafame’s trial, Mr Peter Longson, asserts in his witness statement that he saw Mr Lanzafame’s demeanour visibly change during the playing of the recording in court. That said, Mr Lanzafame’s own counsel, Mr Heath Barklay, stated that at no time during his conversation either that day or at any other time did he see any behaviour or attitude that would cause him to suspect that Mr Lanzafame was at risk of self-harm.

2.7. Mr Lanzafame would end his life the following morning before he could be taken back to court for that day’s proceedings.

2.8. As far as Mr Lanzafame’s medical history is concerned, prior to his remand in custody in December 2014 there does not appear to be any evidence of a significant psychiatric

history. However, during his period of custody the South Australian Prison Health Service (SAPHS) identified ongoing anxiety and depression issues for which olanzapine and mirtazapine had been prescribed.

3. Mr Lanzafame’s interaction with the ARC management and the SAPHS 3.1. Mr Lanzafame was remanded in custody within the ARC from 15 December 2014 until the day of his death which was 24 May 2016, a period of 17 months. For most of that period he occupied single cell accommodation. He was moved into cell 26 of Unit 5 on 20 May 2015. This single accommodation had been requested by Mr Lanzafame. He occupied single cell accommodation for just over a year prior to his death. There is no evidence that the authorities were aware of any attempt at self-harm in that period.

3.2. Mr Lanzafame’s interaction with the ARC staff and the SAPHS was a subject of detailed analysis by the investigating officer Detective Brevet Sergeant Drew Bynoe of the Investigational Assurance Section of SAPOL. Detective Bynoe has described those interactions in his comprehensive investigation report. It is not necessary in these findings to list all those interactions. I will mention some of the salient features.

3.3. On admission to Department for Correctional Services’ (DCS) custody in December 2014, Mr Lanzafame was subjected to the usual DCS admission processes that included a screening for risk. While Mr Lanzafame responded negatively to questions as to whether he had tried to intentionally hurt himself, a score of ten was nevertheless recorded during his admission interview and a Notice of Concern (NOC) was raised in respect of him. That meant that he would be the subject of High Risk Assessment Team (HRAT) intervention. He would also occupy a doubled-up cell, at least to begin with.

3.4. When seen by the SAPHS on admission he was provided with various medications that included diazepam (Valium). He was assessed for alcohol withdrawal and anxiety issues. He was also reviewed by a social worker for potential suicide assessment. On 16 December 2014, when speaking to a social worker, he presented as very anxious and exhibited suicidal ideation, saying that he planned to get access to a screwdriver and expose wires to electrocute himself.

3.5. During the first months of his custody Mr Lanzafame remained under HRAT scrutiny.

In that period he consistently maintained that he had no current thoughts of self-harm.

He was also periodically reviewed by SAPHS staff. A diagnosis of an underlying

depressive illness was made. Ultimately Mr Lanzafame was permitted to leave the Health Centre where he had been accommodated to date and move to a unit where he could smoke and communicate with other inmates.

3.6. On 2 January 2015 Mr Lanzafame was interviewed by forensic psychiatrist Dr Craig Raeside. During Dr Raeside’s assessment of Mr Lanzafame the latter indicated that he had no current suicidal thoughts or intent, but stated that he had made a previous suicide attempt estimated to have taken place in 1997, when he allegedly threw a hose over a tree and tied it around his neck. He asserted that he was cut down by another person.

There was no independent verification of this incident. Mr Lanzafame said that he had seen another psychiatrist eight years previously and that the psychiatrist had cancelled his driver’s licence due to his drinking problem. Dr Raeside assessed Mr Lanzafame as having an adjustment disorder with mixed anxiety and depressed mood. However, he had no clear history of psychosis and no suicidal thoughts, plans or intent. He was cleared to leave the Health Centre which he did on 6 January 2015. He was at first accommodated in Unit 1 in doubled-up accommodation.

3.7. SAPHS notes indicate that on 7 January 2015 Mr Lanzafame denied thoughts of self-harm or suicidal ideation, but stated that if he received an eventual sentence of imprisonment that took him past the age of 60, he would ‘top himself’.

3.8. Mr Lanzafame continued to be monitored by HRAT. Determinations were made that he should remain on HRAT for the time being. On 22 January 2015 Mr Lanzafame was removed from HRAT on the recommendation of the clinical psychologist Ms Nancy Whitaker, who had met with Mr Lanzafame on 16 January 2015. In making that recommendation Ms Whitaker endorsed the casenotes as follows: 'As his case progresses and the evidence against him is presented, he may become more unstable and will likely need support particularly around his court dates.' It will be noted that this observation was made more than a year out from Mr Lanzafame’s eventual trial in May 2016.

3.9. Throughout 2015 Mr Lanzafame was seen by the SAPHS psychologist.

3.10. A short-term analgesic was prescribed for back pain which was one of a number of minor medical issues confronting Mr Lanzafame.

3.11. Mr Lanzafame also saw the ARC social worker. Mr Lanzafame indicated to the social worker that he had felt ready to undertake psychological intervention to manage distress which was believed to have been prompted by Mr Lanzafame receiving the prosecution statements in relation to his murder charge. It is not surprising that Mr Lanzafame reacted in that way to those statements.

3.12. In early July 2015 Mr Lanzafame began cognitive behavioural therapy. Part of that involved the psychologist undertaking baseline measurements of Mr Lanzafame’s depression and anxiety as well as his level of distress which was assessed as severe.

His level of depression and anxiety was rated as moderate.

3.13. Mr Lanzafame was regularly questioned about whether he had thoughts of self-harm.

They were denied. At one point he indicated that he would not take the ‘cowards way out’. On another occasion he did say that he ‘wouldn’t mind a heart attack’. He also said in January 2015 that if a lethal injection was available he would take it.

3.14. Although Mr Lanzafame was no longer subject of HRAT intervention, he was nevertheless subjected to the scrutiny of the Behavioural Management Forum (BMF).

On 14 January 2016 records from that forum indicated that psychological intervention had ceased but that he would benefit from a welfare check around his court dates.

3.15. As indicated earlier, on 1 March 2016 the ARC instituted its non-smoking policy.

3.16. Notes from the BMF dated 17 March 2016, confirmed that further welfare checks were to be conducted in respect of Mr Lanzafame at the time of his court proceedings. By then it had been established that his trial commencement date would be 16 May 2016.

3.17. A psychiatric review was conducted on 30 March 2016. Mr Lanzafame indicated that he was very anxious about his court trial. Mr Lanzafame’s management plan was not altered.

3.18. During a routine search of Mr Lanzafame’s cell on 2 April 2016, an excessive number of unused nicotine patches were located. Mr Lanzafame was warned in respect of this.

The DCS had a Volunteer Quit Smoking Team. Its leader, Ms Sharon McLean, interviewed Mr Lanzafame on 5 April 2016. Mr Lanzafame said that he had smoked 60 cigarettes a day for 43 years which means that he must have commenced smoking at about the age of 9. He expressed resentment and stress at having been forced to give

up smoking which he said was a release for him. He said that he was suffering physical withdrawal symptoms including sweats, constipation and anxiety about his pending trial. He pulled up his top to reveal that he was wearing three nicotine patches on his chest. Ms McLean was concerned about the number of patches and advised him to place these on his arms or upper thighs. A further meeting with Ms McLean occurred on 12 April 2016. On this occasion he stated that he missed and craved cigarettes. He was still using patches. The statements of other prisoners suggest that Mr Lanzafame was pre-occupied with his inability to smoke, wore nicotine patches that were in excess of what was recommended and that they did not work for him.

3.19. On 28 April 2016 Mr Lanzafame attended the Health Centre with increased agitation and anxiety given that his trial was three weeks away. He expressed no thoughts of self-harm. He requested a temporary increase in olanzapine which was granted. It was increased from 5mg to 10mg for one month.

3.20. Mr Lanzafame was seen by SAPHS in the days preceding the commencement of his trial. He denied any thoughts of self-harm or suicidal ideation.

3.21. Mr Lanzafame’s trial commenced on 16 May 2016. The Unit 5 log records that for the duration of his trial Mr Lanzafame was consistently removed from his cell between 7:15am and 7:30am which was in advance of the usual unlock time of 8:40am. It is recorded that on those trial days he was returned to his cell consistently between 5pm and 5:30pm which was after the usual lockdown time which was at 4:40pm. A Sentencing Management Unit member recorded on 20 May 2016 that Mr Lanzafame was re-booked for BMF review the following week as he had been absent in respect of court commitments. Mr Lanzafame’s death intervened.

3.22. Prisoner telephone system records reflect that on the weekend during Mr Lanzafame’s trial he made a number of calls to a friend, Mr May, and to his son. The calls do not reflect any suicidal ideation or expression. During the weekend Mr Lanzafame interacted with other prisoners during non-locked down periods.

3.23. On 23 May 2016, which was the Monday after that weekend, the Unit 5 log records that Mr Lanzafame was returned to his Unit at 5:30pm. Regular patrols were conducted at 12:13am, 2:04am, 4:05am and 5:55am, roughly every two hours. It was when correctional officers went to remove Mr Lanzafame from his cell for the purposes of court that day that he was discovered deceased. Mr Lanzafame was provided both with

the physical means to hang himself and with the necessary time in which to carry out that act. This Court has commented in the past on the futility of night patrols as a safety measure when carried out at the frequency described above. I speak here of the inquest in the matter of Costi which I shall further discuss in a moment.

3.24. There is no evidence that on the days of his trial Mr Lanzafame was seen by anyone in the ARC by way of Prison Health Service intervention or was the subject of any other type of intervention or scrutiny.

4. Discussion of the issues and conclusion 4.1. The issues identified in this inquest bear similarities to those identified and discussed in other coronial inquests involving deaths in custody in South Australian correctional institutions. The most recent of those involved the inquests into the deaths of John Steve Costi4 who died in November 2013 at the ARC. The other matter involved the death of Safar Ali5 who died on 10 April 2015 at the Yatala Labour Prison. Both of those deaths involved hangings in singularly occupied cells, although in Mr Ali’s case his death did not occur during a lockdown period. The central issues involved in those inquests and in this inquest were lack of regular prisoner stress screening and hanging points in cells.

4.2. In both of those previous cases this Court’s conclusion was that there had been nothing to suggest that either prisoner required doubled-up accommodation in the period approaching his trial or during his trial. Mr Ali in fact committed suicide during his trial, like Mr Lanzafame.

4.3. In Mr Lanzafame’s case I do not believe that the authorities departed from any formal requirements or standard operating procedures. To my mind there was nothing to suggest that Mr Lanzafame was at imminent risk of committing an act of self-harm during his trial. It is true that during that trial he does not appear to have received any particular or special support. However, after a year of incident free single accommodation it would have been a very long bow to draw to suggest that Mr Lanzafame had displayed a demonstrable risk of suicide.

4 Inquest 02/2017 5 Inquest 14/2018

4.4. I agree with the conclusion reached by the investigating police officer, Detective Bynoe, that Mr Lanzafame’s suicide could not have been prevented other than by having him accommodated either in a doubled-up cell or in a cell that did not contain the hanging point that he utilised. The existence of the hanging point in the cell was the dominant contributing factor in Mr Lanzafame’s suicide.

4.5. This of course brings me to the question of hanging points in cells generally. As discussed in the findings of Costi and Ali, and in many other findings preceding those in this State and in other States, it has been recommended that in keeping with safe cell design, hanging points should be eliminated from cells. The hanging point in Mr Lanzafame’s cell was one that could be readily identified by a prisoner intent on self-harm. The Court in this case repeats the many recommendations made in previous cases and that is that, regardless of the type of accommodation within the prison system and regardless of the risk assessment pertaining to a particular prisoner, hanging points should be eliminated from cells, especially those that provide single occupancy. I so recommend.

4.6. As to the question of ongoing prisoner stress screening, it is noted, as has been noted in other coronial matters, that DCS Standard Operating Procedure 90 (SOP 90) now stipulates that correctional officers are to be vigilant for any signs of distress when prisoners, particularly HRAT prisoners, return from any escort, including court appearances. If a correctional officer has any concern about a prisoner returning from such an escort they must verbally notify a responsible officer and complete a Notice Of Concern. That would then result in a risk assessment being undertaken in respect of the prisoner in question and they will be placed on HRAT intervention. DCS appears to be determined to maintain its view that routine stress screening for prisoners on return from court is neither necessary nor practicable. I have nothing further to say in relation to that issue except to observe, as I observed in the matter of Ali, that correctional authorities should be mindful of the fact that a lay and cursory examination of a prisoner for signs of distress upon being returned to a correctional facility following a court appearance, would not necessarily reveal any underlying distress or identify a risk of self-harm.

4.7. I do not believe that it was unreasonable for Mr Lanzafame not to be doubled-up for the duration of his trial. I also do not believe that, as has been discussed in evidence in this inquest, there is a need for prisoners who have been consistently accommodated in

a single cell without incident to be routinely, and for no compelling reason relating to their safety, be doubled-up during their trials. This might only add to their difficulties in what is an already stressful set of circumstances. That said, obviously there would be cases where, due to a specific and acute perceived risk, doubling-up of a prisoner would be highly desirable if not necessary. In Mr Lanzafame’s case he had been accommodated in a single cell for a year without adverse incident. Only with the benefit of hindsight could it be said that consideration should have been given to his being doubled-up during his trial. But the difficulty was that he was accommodated in a cell that had an obvious hanging point. The fact that Mr Lanzafame, a man who for myriad reasons had clearly struggled with his custodial circumstances, was singly accommodated in a cell that had a hanging point was to say the least, undesirable and should never be repeated.

Key Words: Death in Custody; Suicide; Prison; Hanging Points; Safe Cells In witness whereof the said Coroner has hereunto set and subscribed his hand and Seal the 15th day of December, 2021.

Deputy State Coroner Inquest Number 80/2020 (0936/2016)