‘Astounding' negligence revealed: governments turn blind eye to staggering prison death toll

The Guardian

09-06-2025

Warning: this story contains descriptions of self-harm and some readers might find it distressing.
A staggering 57 Australians have killed themselves in the past two decades using hanging points in prisons that authorities knew about but failed to remove, a Guardian investigation has found.
In a five-month review of 248 hanging deaths in Australian jails, Guardian Australia identified 19 correctional facilities where inmates died after governments and authorities failed to remove known ligature points within cells.
In many cases, this was despite repeated and urgent warnings from coroners to do so.
Families of the dead, former state coroners, justice reform experts and former federal ministers have expressed their shock at the 'astounding' failures of successive state governments to fulfil promises made after the royal commission into Aboriginal deaths in custody more than 30 years ago to remove such hanging points.
Guardian Australia has spent five months investigating the deadly toll of Australia's inaction to remove hanging points from its jails, a key recommendation of the 1991 royal commission into Aboriginal deaths in custody.
The main finding – that 57 inmates died using known ligature points that had not been removed – was made possible by an exhaustive examination of coronial records relating to 248 hanging deaths spanning more than 20 years.
Reporters combed through large volumes of coronial records looking for instances where a hanging point had been used repeatedly in the same jail.
They counted any death that occurred after prison authorities were made aware of that particular hanging point. Warnings were made via a prior suicide or suicide attempt, advice from their own staff or recommendations from coroners and other independent bodies.
Guardian Australia also logged how many of the 57 inmates were deemed at risk of self-harm or had attempted suicide before they were sent into cells with known hanging points.
In adherence with best practice in reporting on this topic, Guardian Australia has avoided detailed descriptions of suicide. In some instances, so that the full ramifications of coronial recommendations can be understood, we have made the decision to identify types and locations of ligature points. We have done this only in instances where we feel the public interest in this information being available to readers is high.
The worst offender was Queensland's Arthur Gorrie correctional centre, where 10 prisoners killed themselves using the same type of ligature point – exposed bars that authorities knew about but failed to remove.
The hangings continued until 2020 despite coronial warnings as early as 2007 that the state government 'immediately make available sufficient funding to enable the removal of the exposed bars'. The same coroner had told authorities the bars 'could easily be covered with mesh' following an earlier death.
The same failure was repeated across the state, at Townsville correctional centre, where two inmates were able to hang themselves from known ligature points, and at Ipswich's Borallon correctional centre, where two others died in an almost identical way.
The problem is not isolated to Queensland.
At the Darwin correctional centre cells were equipped with overhead fixtures that could bear body weight, creating what coroners called a 'classic' hanging point. They were used in two deaths within two years of the prison's opening in 2014 and were not completely removed until 2020.
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In South Australia the Guardian found 14 deaths from hanging points that were known but not removed, including at the Adelaide remand centre.
At least five prisoners have hanged themselves from fixtures at Hakea prison in Western Australia, despite warnings to the state government as early as 2008 it should address all obvious ligature points.
Sydney's Long Bay correctional complex recorded five hangings from bars between 2000 and 2017, despite a warning in 2009 that the 'obvious' hanging points had to be removed.
Across New South Wales the Guardian identified 20 deaths from hanging points known to authorities but not removed, including at Goulburn, Parklea, Bathurst and Cessnock prisons.
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Guardian Australia asked every state government what has been done to address the problem. You can read their responses in full here.
The revelations have prompted renewed calls for action from victims' families.
Cheryl Ellis lost her son, Gavin, to suicide in the Darcy unit of the metropolitan remand and reception centre in Sydney's Silverwater prison complex in 2017.
The 31-year-old had a longstanding psychotic illness and was a known suicide risk. In his first three days in custody he tried to hang himself twice but was not seen by a mental health clinician for eight days and was not reviewed by a psychiatrist for six weeks. He was sent to a cell with a hanging point – a set of window bars. Another inmate had died by hanging from window bars in the Darcy unit two years earlier.
The bars remained in the unit cells after Gavin's death and were used in a third suicide in 2020. The inquest into Gavin's death recommended that all obvious hanging points be removed but delays in the coronial system meant that recommendation did not come until two years after the third suicide.
The NSW government would not say whether the bars have now been removed.
Cheryl says her son should never have been sent to that cell. She also says the hanging points should not have been allowed to remain in the Darcy unit cells after Gavin's death. 'The system does not have capital punishment yet it leaves hanging points for inmates to use,' she said.
Official data shows suicide by hanging remains the most common cause of self-inflicted death in custody. Considerable progress was made to reduce the rate of hanging deaths in the late 1990s and early 2000s. That progress has stalled since 2008, the data shows.
The continued presence of known ligature points is just one factor contributing to hanging deaths.
The 248 deaths investigated by the Guardian often involve multiple failings, including breakdowns in psychiatric assessments and a failure to provide proper mental health care, the lack of suitable beds in secure mental health facilities, the absence of proper observation regimes and mistakes in information sharing and cell placement.
Deaths in custody continue to disproportionately affect Indigenous Australians, who remain vastly overrepresented in prison populations. Seven Indigenous Australians hanged themselves in 2023-24, a number not recorded since 2000-01.
Robert Tickner, the former Labor federal Indigenous affairs minister, led the Australian government's response to the 1991 royal commission into Aboriginal deaths in custody. He helped to secure the agreement of state and territory governments to remove hanging points from their prisons, something he describes as a 'no brainer'.
'There can be no excuses for the failure to act,' he said. 'My very strong view is that the ultimate buck stops with the commissioners of corrections and governments.'
Michael Barnes, a former state coroner in Queensland and New South Wales, said the number of deaths from known ligature points was 'astounding'.
'It's hard to think that it's anything other than a lack of commitment that can explain the continuing high rate.'
In Australia, the crisis support service Lifeline is 13 11 14. Indigenous Australians can call 13YARN on 13 92 76 for information and crisis support. Other international helplines can be found at befrienders.org