A coroner has ruled that a prisoner who took his own life in the back of a transport vehicle in 2015 received “unacceptable” treatment and supervision from the Tasmania Prison Service.
Troy Colin Monson, 42, of Wynyard, died on June 22, 2015, as he was being transferred from the Launceston Reception Centre to Risdon Prison.
Mr Monson’s death was followed by two more in the Hobart prison in the space of a month.
Robin Michael, 63, of South Australia, was believed to have taken his own life in his prison cell, while Scott Clifford Mitchell, 23, seemed to have died as a result of a medical condition.
A coronial inquest was established in 2015 to probe the deaths.
On Friday, Coroner Simon Cooper handed down his findings in the Hobart Coroners Court.
He concluded that when Mr Monson was remanded in Burnie, he was not cared for, supervised or treated at an “acceptable standard”.
Coroner Cooper said Mr Monson was expressing suicidal ideation while in custody, for which he was not afforded due care.
Once transferred to the Launceston Reception Centre, Mr Monson was not assessed in relation to his mental state and capacity for self-harm.
Nonetheless, he was prescribed what Coroner Cooper called an “atypical” anti-psychotic medication, which the coroner said was “unacceptable”.
Coroner Cooper described the decision to transfer Mr Monson to Hobart as “a poor one”.
The court heard that the escort officer and driver tasked with getting Mr Monson from Launceston to Risdon Prison were not informed of the reason for his transfer.
Neither, apparently, were they informed of his suicidal ideation.
Mr Monson died at about the time the vehicle was passing through Perth.
Coroner Cooper said he had reached the conclusion that the accompanying officers had not properly monitored the CCTV footage in the front of the vehicle.
“From the correctional systems’ point of view, the death of Mr Monson is without question the most troubling,” Coroner Cooper said.
“But for the multiple systems failures on the part of the TPS, Mr Monson’s death was eminently avoidable.”
The coroner told the court he was satisfied that Mr Michael and Mr Mitchell had been “appropriately treated … [and] cared for” by both the TPS and Ambulance Tasmania.
The coroner’s report contained 18 recommendations, including:
- That the TPS engage a medical practitioner for consultations at the Launceston Reception Centre;
- That up-to-date prisoner assessment forms be provided by Tasmania Police to the TPS when custody of a prisoner is transferred from one location to another;
- And that an appropriate vehicle be purchased by the TPS to allow for special escorts to be carried out safely.
Coroner Cooper extended his condolences to the family and friends of the three men.
Acting Corrections Minister Guy Barnett said the government would “carefully consider” the coroner’s recommendations.
“We continue to work to improve all aspects of the prison system to keep inmates and staff safe,” he said.
“On behalf of the government I once again extend my deepest sympathies to the families of the three men.”
Mr Barnett noted that, following the three deaths, the Hodgman government had established new support systems designed to prevent “avoidable” deaths in custody.
Tasmania Police released a statement relating to the coroner’s findings, saying it, too, would consider the report.
“Tasmania Police takes its responsibilities in relation to the safety and welfare of people in our care very seriously,” the statement read.
If you or someone you know struggles with mental health issues, contact Lifeline on 6282 1500.