Finding into death of Benjamin Elijah Mills

IN THE CORONERS COURT OF VICTORIA AT MELBOURNE

Court Reference: 2013 / 0593

FINDING INTO DEATH WITH INQUEST

Form 37 Rule 60(1) Section 67 of the Coroners Act 2008

Inquest into the Death of: BENJAMIN ELIJAH MILLS Delivered On: 15 October 2014

Delivered At: Coroners Court of Victoria 65 Kavanagh Street, Southbank, Victoria, 2006

Hearing Dates: Thursday 29 May 2014 Findings of: JUDGE IAN L GRAY, STATE CORONER Representation: Ms D Coombs on behalf of Corrections Victoria

Police Coronial Support Unit Leading Senior Constable King Taylor

I, JUDGE IAN L GRAY State Coroner, having investigated the death of Benjamin Elijah Mills

AND having held an inquest in relation to this death on Thursday 29 May 2014 at Melbourne find that the identity of the deceased was Benjamin Elijah Mills born on 11 July 1981 and the death occurred on or about 8 February 2013 at, Banksia Unit, Barwon Prison, 1140 Bacchus Marsh Road, Lara from: 1 (a) HANGING

in the following circumstances: Background

1. Benjamin Mills (Mr Mills) was a 31 year old man serving a term in prison at the time of his

death. It was his sixth term of imprisonment.

2h His current term of imprisonment commenced on 7 June 2010 with a sentence of 12 years and 6 months (with a non-parole period of 5 years and 6 months). The sentence related to offences of armed robbery, theft, attempted armed robbery, reckless conduct, possess drug

of dependence, burglary and breach of parole.

3, He was transferred to Barwon Prison, Lara on 17 March 2011 and was housed in the Grevillea Unit.

4. An incident occurred in relation to an assault on another prisoner on 24 November 2011

which caused Mr Mills to later be transferred to the Banksia Unit around 21 December

Dy He was housed alone in Cell 10, was on the bottom tier of the two storey level unit.

6. He received a rating of 3 under the prison incentive based regime which was the highest

level. This resulted in his position as a Unit billet (a worker within the unit) which was deemed as a reward for good behaviour. His position was as the laundry billet which required him to keep the laundry area clean and do all the laundry for the downstairs prisoners. The position allowed him access to the secure area outside his cell which was the

corridor down to the laundry. The laundry area contained items such as mops and brooms.

These items were not locked up and there was no register requiring the signing out of

equipment.

Circumstances proximate to the death

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On 8 February 2013 Mr Mills was locked into his cell in the afternoon sometime around

3.30pm — 4.00pm as per procedures. His cell was not searched that evening.

During the evening and subsequent night, Mr Mills placed pillows under the covering on his bed which gave the impression that he was present in bed. A sheet was placed on a strip fabric running from a hook in the air vent over the bathroom mirror to the shower wall pole.

This partially obscured the view from outside the trap door into the cell. An aluminium mop was placed vertical up against the shower wall beside the wash basin. Attached to the top of the mop handle, was a white singlet and a black ligature. This ligature was from the fabric that is used to wrap around boxers knuckles and wrists, was tied in a knot and was hanging down towards the ground. A plastic chair from the cell was placed in the shower recess up

against the shower screen. The back of the chair was facing the shower wall.

Mr Mills appeared to have entered the shower area attached the ligature around his neck and

positioning his body behind the back of the chair.

It appears he positioned himself so that the ligature became tight on his neck resulting in

strangulation.

Mr Mills was not checked by prison staff during the night.

The following morning, Saturday 9 February 2013, prison staff were in the process of issuing breakfast to the inmates. At about 7.30am, prison staff were unable to elicit a

response from Mr Mills when Cell 10 was checked.

A Code Black (prisoner death/serious medical) was call at 7.36am which resulted in

additional staff attending and the cell was entered.

Mr Mills was located slumped up against the wall of the shower area next to the basin. The ligature was cut by prison staff and Mr Mills removed from the cell. CPR was commenced

until an ambulance arrived. Mr Mills was unable to be revived.

A search of the cell located a handwritten suicide note on the bench.

At the time of his death, Mr Mills was receiving psychological treatment for depression. He

was last seen by a registered psychiatric nurse on 7 February 2013. He had become flat,

low, anxious and tearful. Though he indicated ongoing thoughts of suicide, he denied any plans or ideation to kill himself. There were plans in place for him to be transferred to the

Hoya Protection Unit for his safety however an exact date had not been finalised.

The Autopsy

Dr Malcolm Dodd performed the autopsy on 12 February 2013. He expressed the medical cause of death as “Hanging”. He noted that “that the deceased was a self diagnosed manic depressive and had been seeing a prisoner psychologist and nurse for this condition” and

“there was no apparent suicidal ideation”.

The Inquest

A short summary inquest was conducted in this matter. Corrections Victoria was represented by Ms Deborah Coombs. I was assisted by Leading Senior Constable King Taylor and Mr Roberts Mills, Benjamin’s father appeared to represent the next of kin and family.

The Investigating Member/Coroners Investigator gave evidence by way of a summary of the

history and the circumstances in the matter.

At the conclusion of the inquest, Mr Robert Mills made a number of comments. His focus was on the regularity of observation of his son and on the provision of medical/clinical

support or other assistance to him.

As usual in prison deaths, the Office of Correctional Services Review (OCSR) investigated the death, provided a report detailing the circumstances of the death with an overview of his

management and made two recommendations.

Justice Health also investigated the matter, noted the OCSR recommendations and made

some comment about those. Justice Health did not make separate recommendations.

The OCSR report itself is a confidential document but the recommendations can be published,

After a detailed and comprehensive investigation and review, the OCSR made two

recommendations:-

1. That Correction Victoria amends relevant policies for the management of at-risk prisoners to articulate the expectations and obligations of Corrections Victoria

clinicians in relation to reporting requirements and the use of professional discretion.

27. That Corrections Victoria embeds in policy the practice of removing and disposing of

all makeshift hooks in Building Design Review Program-compliant cells.

Corrections Victoria accepted the recommendations in principle and I was informed and

accept that the OCSR would monitor the implementation of the recommendations.

Recommendation 1 That Corrections Victoria amends relevant policies for the management of at-risk prisoners to articulate the expectations and obligations of Corrections Victoria clinician in relation to reporting requirements and the use of

professional discretion.

On 29 November 2013, “Commissioner’s Requirement — Management of At Risk Prisoners and Deputy Commissioner’s Instruction 1.02 —At Risk Prisoners”, was amended and issued to all staff. Among the amendments was that clinical staff are to use their professional judgement and discretion when exchanging information with custodial staff about prisoners,

balancing duty of care obligations, with the need to preserve client confidentiality.

In his advice to the Court, the Secretary of the Department of Justice stated:- “In practice, these amendments allow clinical staff to use their discretion when deciding whether or not to share information with custodial staff about a prisoner that potentially relates to self harming behaviour. In providing feedback on the draft report, Corrections Victoria explained that this discretion is important for clinical staff in developing and maintaining

therapeutic relationships with prisoners.

Recommendation 2: That Corrections Victoria embeds in policy the practice of removing and disposing of all makeshift hooks in Building Design Review Project (BDRP)-complaint

cells.

The response to this was that on 1 December 2013, the Deputy Commissioner emailed prison General Managers and Operations Managers, to remind them to ensure staff remove all items, including any makeshift hooks, that prisoners are not permitted to have in-cell, particularly if it is a Building Design Review Project compliant cell and the items be used

for self-harming purposes.

Notification of Mr Mills’ Next of Kin

In this case I was informed that Victoria Police reported attending Mr Mills’ home three times on 9 February 2013 before leaving a card advising that the recipient telephone the

prison. Victoria Police did not make Barwon Prison aware of the referral. When Mr Robert

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Mills telephoned Barwon Prison and spoke to the General Manager, the General Manager was not aware that there had been failed attempts to notify him of his son’s death. The General Manager did not in fact inform Mr Robert Mills of Benjamin’s death. It was accepted by the General Manager and by the OCSR that the situation was “less than ideal” as a notification process and that it may have caused further distress to Mr Robert Mills.

I am advised, and accept, that the “short comings of next of kin notification in this instance were identified at the formal incident debrief and a recommendation posed that Corrections Victoria consider amending the memorandum of understanding with Victoria Police. In consultation with Victoria Police, Corrections Victoria has since amended the memorandum to ensure that Victoria Police advise the prison location when a next of kin notification has

been made”.

As a consequence of this death, Corrections Victoria amended the Commissioner’s requirement, and the Deputy Commissioner’s instruction 1.20 that Victoria Police advise

the prison location when a next of kin notification has been made.

Also as a consequence of this death, Corrections Victoria amended the Commissioner’s requirement, and the Deputy Commissioner’s instruction 1. Deaths in Prisons. They did so to reduce the risk of a repeat of this situation by ensuring that Victoria Police had all available information to conduct the notification and that the prison location is aware of

when the notification is made or has been made. These are appropriate amendments.

As a consequence of the actions taken by Corrections Victoria, as a result of it’s review and the review by Justice Health, it is not necessary make further recommendations for system

change arising out of Mr Mills’ death.

The issue about the materials used by Mr Mills in his cell was dealt with in detail by the OCSR review. Immediately after the incident, at a formal incident debrief, Barwon Prison resolved to ensure that all cleaning equipment in high security management units was accounted for at the end of each day and that such items were to be used by staff on “an as needs” basis only. I note that in the OCSR review process there was an acceptance of the need for a tightening up of procedures to ensure that mops, brooms and other equipment of that nature would not be able to be returned to a billet’s cell. The OCSR reported that it was satisfied that the changes to procedures in respect of the use of cleaning equipment have mitigated the risk of prisoners retaining cleaning equipment in their cells and reduced the

risk to staff and prisoners alike while maintaining a “practical approach to cell cleanliness”.

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Sion

Relevant manuals and instructions have been amended to ensure that this happens. I accept

that these were appropriate and balanced response.

The OCSR report dealt in detail with Mr Mills’ access to out of cell hours and his social supports.

In relation to his health, Justice Health reviewed Mr Mills’ medical file and noted that Mr Mills received regular support from mental health staff. Mr Mills’ mental health management decisions were made following assessment of his mental state and were informed by the knowledge gained through ongoing contact with the mental health

professionals throughout his incarceration.

On reviewing the evidence, and the findings of the OCSR report, it is reasonable to conclude that Mr Mills was receiving appropriate medical and psychological support within the prison. In addition he was able to take a substantial number of out of cell hours, he was able to interact with staff and other prisoners, and he was able to make regular telephone contact with his mother. I note that he received three visits from his father in 2012, the most recent

prior to his death being on 24 December that year.

In relation to Mr Robert Mills’ concerns about his son’s worsening mental/emotional state towards the end of this life, I note that the reviews dealt thoroughly with the question of observation, and the provision of counselling, psychiatric, psychological and medical services to Mr Mills. I note also Ms Coombs’ submission to the effect that a prisoner with Mr Mills’ status doesn’t automatically receive a heightened level of observation. Whilst he was not a protection prisoner, his status meant that he was not observed more frequently than actually occurred, and he was not required to be. I do not consider it appropriate to make any recommendation for further review or change of the observation regime

applicable to a prisoner of Mr Mills’ classification/status.

On review of the material and taking into account the matters raised by Mr Robert Mills, there is no basis to criticise or comment adversely on the provision of medical treatment, psychological counselling, or psychiatric assistance. As noted earlier (paragraph 16) he was

seen by a psychiatric nurse the day before his death.

In relation to the completely understandable concerns that Mr and Mrs Mills had about their son’s descent into a worsening depression, I note that a short series of telephone calls made

by Mr Mills prior to his death was one of the issues reviewed.

39. As part of this investigation, the OCSR reviewed a short series of telephone calls made by Mr Mills prior to his death.’ Notably, Mr Mills describes descent into deep depression in his last telephone conversations with his mother on 2 and 3 February 2013. he describes

experiencing depression and anxiety as ‘worse than it’s ever been’.

40. In his last telephone conversation with his father on 6 February 2013, he also describes feeling more depressed that he has previously experienced, explaining ‘it just gets worse and worse, dad’, and that he is on medication ‘but it’s not working’. However, Mr Mills also stated that he was receiving intensive treatment — ‘I’ve got a psych coming to see me all the time [...] she’s been really good’ — and that he had ‘some good people helping him through’.

41. Sadly it is clear that despite the assistance he himself acknowledged, Mr Mills had reached a point where he had decided to end his own life. I am satisfied that he did so intentionally.

The fact that he was able to utilise a mop handle to do'so was the system failure identified in

this case, and that has been rectified.

42. | formally find that Mr Benjamin Mills died from hanging and that he intended to take his

own life, the death occurring on or about 8 February 2013.

I again convey my condolences to the family of Benjamin Mills

I direct that a copy of this finding be provided to the following: Mr Robert Mills Corrections Victoria

Leading Senior Sergeant King Taylor

Signature:

FR

JUDGE IAN L GRAY STATE CORONER

Date: SP, (ek.

' The OCSR reviewed the 33 personal telephone calls made by Mr Mills between 10 January 2013 and 9 February 2013.