Failures in supervision led to suicide in Canberra's jail, coroner says

An ACT coroner has found that failures in the supervision of a detainee who died by suicide at Canberra's jail contributed to his death, recommending changes to prison procedures and mental health services.

Justin James Cordy, 34, died on February 26, 2023, two days after being arrested by ACT Policing and five days after being released from prison.

In findings released last week, Coroner Lucinda Wilson said Mr Cordy had been given access to items he used to take his own life and was not adequately observed in the hours before his death.

Inadequate supervision

Mr Cordy was transferred to the Alexander Maconochie Centre (AMC) on Saturday, February 25, 2023, after appearing before an ACT court. He had a history of substance abuse and previous convictions, and had previously attempted suicide while in custody in 2020.

In the days before his arrest, police had also been told Mr Cordy had expressed suicidal thoughts and was concerned about returning to prison. The inquest examined his treatment by police, his mental health assessments and the systems in place to monitor detainees at the AMC.

Ms Wilson found that the availability of materials used for his suicide, combined with inadequate supervision, contributed to his death. She said adequate observation may have identified Mr Cordy's preparations and prompted intervention.

The report found the prison's systems for checking cells at the time were inadequate.

CCTV showed an officer looking through the flap of Mr Cordy’s cell door at 11:40am, but not opening it. No further checks were visible before 1:03pm, despite an observation form recording a check at midday. The coroner recommended changes to cell inspection procedures, including requiring officers to enter cells when conducting visual checks.

The coroner also recommended correctional officers conduct and document spot checks of systems for storing and tracking cleaning equipment.

Concerns about police custody

The inquest also examined Mr Cordy's treatment following his arrest on February 24, after police had been alerted to concerns about his mental health, including reports that he had threatened suicide.

Mr Cordy was arrested after allegedly stealing a car and fleeing police, who tasered him. An alert about his mental health had not been shared with arresting officers. He also cut his wrist with a knife before the arrest, but police failed to inform paramedics or hospital staff.

The coroner found aspects of the care he received in police custody were substandard and raised public safety concerns. However, she concluded those failures did not contribute to his death.

"This report contains discussion about what could have, and should have, occurred in relation to Justin's care, treatment and supervision from the time he entered AFP custody until his death in the AMC," the coroner said.

"Much of that discussion has considered hypothetical situations, the outcome of which cannot be known, and I have found, if certain actions had occurred, they would not have prevented Justin's death."

At the time of his arrest, he was covered in cuts and was bleeding, and requested an ambulance.

The coroner said despite the self-inflicted wounds, the paramedics would have spent 10 minutes at most with Mr Cordy.

Mr Cordy was later assessed at Canberra Hospital before being taken to the ACT Watch House two hours later.

She recommended further written guidance and training for ACT Policing officers on assessing detainees' physical and mental health, communicating concerns and ensuring appropriate medical assessments.

Saturday court mental health services

Coroner Wilson also raised concerns about the resourcing of the ACT Magistrates Court's Saturday bail list.

The Mental Health Court Assessment and Liaison Service, which provides assessments and advice to the court on weekdays, did not operate on Saturdays.

She recommended that Canberra Health Services extend the service to every day bail hearings are held, including weekends and public holidays.

In her concluding remarks, Coroner Wilson said she hoped the failures in Mr Cordy's supervision would not happen again, so another family would not have to endure the loss experienced by his loved ones.