Latest news with #coroners
ABC News
08-07-2025
- ABC News
Upgraded safety barriers for Hobart's Tasman Bridge needed as coroners warn of suicide risk
A coroner's report has found there is an "immediate need" for the installation of safety barriers on Hobart's Tasman Bridge. Warning: This article contains details that readers may find distressing. Four coroners wrote the report due to a disproportionate number of deaths by suicide, which has continued since the last coroner's report on the issue in 2016. Its release coincided with the publishing of findings into nine deaths. The report noted that safety barriers had reduced suicide deaths on Brisbane's Story Bridge since their installation in 2015, and resulted in no deaths on Melbourne's West Gate Bridge since 2011. It found that similar works must be progressed for the Tasman Bridge. "Findings in this report further emphasise the immediate need for structural intervention through the installation of a safety barrier," the report reads. In 2022, the Tasmanian government released a concept plan for the Tasman Bridge that included wider pathways for cyclist and pedestrian safety, and higher safety barriers. The upgrades were expected to be complete by this year, but the design was changed in 2024, with the government citing a significant level of structural changes that would be needed. There are now plans for a three-metre-high safety barrier on the water side, and a 1.4-metre-high barrier on the traffic side. The plans also include improving pathway connections on the eastern and western shores, exploring 'one-way pathway' options for each side of the bridge, and adding passing bays and a slightly wider pathway. A spokesperson for Tasmania's Department of State Growth said the improvements would occur in the near future. "Targeted consultation has already occurred and we will be seeking broader public feedback on the designs for the bridge pathways and barrier designs in the coming months. "Pending the outcome of that consultation, construction is targeted to start later in 2025 and be complete in late 2026." The 2016 report made seven recommendations, including the installation of additional camera surveillance and an assessment of the effectiveness of telephones and signage on the bridge. Police attend an average of 195 "concern for welfare" incidents per year on the bridge, and there are an average of 2.6 deaths by suicide per year — about 3 per cent of total suicides in Tasmania. The data came from the Tasmanian Suicide Register, which was established as part of one of the 2016 recommendations. The coroners' report released this week found that more improvements are needed to build on these recommendations. "Measures such as camera surveillance, police data and the Tasmanian Suicide Register are important for investigation and reporting purposes," the report reads. The 2016 report also recommended that the government formulate a "plan" for structural modifications on the bridge, with a key aim of eliminating suicide risk. Graeme Peck has been pushing for safety improvements on the bridge for over a decade, and is part of a consultation group run through the Department of State Growth, along with cycling and pedestrian advocates. He said he was pleased to see works coming closer to fruition to prevent further deaths by suicide. "I think State Growth — all of the people directly involved in this — have now got all the facts, there's two coroners reports, no-one can defend not going ahead with it," Mr Peck said. "It will also make it safer for cyclists and pedestrians from falling into traffic … the one-way arrangement will add to it being more efficient and safer."
CTV News
04-07-2025
- CTV News
B.C. field coroners get $32 an hour to face scenes of death. Some say it's not enough
Bullet holes are seen in the windshield and hood of an SUV as a coroner and investigators attend the scene in Vancouver, B.C., Wednesday, April 17, 2019. THE CANADIAN PRESS/Darryl Dyck They work on gruesome scenes of death, sometimes traversing rough terrain to access bodies in various states of decomposition. British Columbia field coroner Leena Chandi said the things that she and her colleagues encounter 'are not what most people see, and nobody should have to see that.' 'But somebody has to do the job, and somebody has to care about that person.' Yet field coroners say they are among the most underpaid workers in the province's emergency services sector, receiving just over $32 an hour as they work on scenes that can be risky and stressful. And while field coroners work on call they are not paid for their time waiting to be sent to a scene of death. The province's field coroners are now hoping to improve their situation, sending a letter to their bosses and members of the legislature in an 'urgent' plea for an increase in pay that they say has stagnated for nearly a decade. The letter, obtained by The Canadian Press, says field coroners — who differ from full-time investigative coroners — haven't had a wage increase since 2016 and high inflation and the rising cost of living make the job unsustainable. 'The financial strain imposed on field coroners by the failure to update wages has led to recruitment and retention challenges,' the letter says. 'Many experienced professionals are forced to leave the role in search of more sustainable employment, leading to service gaps in our communities.' The coroners service says it investigates 'unnatural, sudden and unexpected, unexplained or unattended deaths.' It says coroners determine the identity of a deceased person; when, where and how they died; and how the death should be classified — for example, whether it is natural, accidental or homicide. Chandi said she joined the service last fall, banking on a background in insurance fraud investigations, and she and a group of around 10 colleagues have endorsed the letter's call to urgently increase field coroner pay. Chandi, who lives in Surrey, B.C., said in an interview that the letter was distributed to upper management, including Chief Coroner Dr. Jatinder Baidwan, but so far there's been no response or official acknowledgment of their concerns. She said she has a co-worker who is a single mother who 'can barely pay her rent.' The BC Coroners Service said in a statement that it is working with the Public Safety Ministry to determine the best path forward in addressing compensation for field coroners. 'This work reflects our shared commitment to supporting those who serve in this essential role. Finding a resolution to this matter remains a priority,' the statement said. The coroners service website says there are approximately 50 full-time investigative coroners and around 85 so-called community coroners, also known as field coroners, whose part-time positions are paid according to hours worked. The letter says there's a 'glaring inequity' between how investigative coroners and field coroners are paid, despite the risks faced by the latter who attend calls when people have died. It says investigative coroners have had consistent pay raises in the last few years, and they 'work in hybrid, work-from-home positions with no exposure to hazardous environments.' 'This means investigative coroners, who do not face the same risks or responsibilities as field coroners, earn significantly higher wages, along with pensions and benefits,' the letter says. 'In contrast, field coroners continue to put themselves in high-stress, high-risk situations without fair compensation or basic job protections.' It noted that field coroners work on call but are not paid for wait time. 'We are expected to be available round-the-clock, often waiting for extended periods before being dispatched, without any remuneration for our readiness. This practice is fundamentally unfair and does not align with the standards set for emergency service professionals,' the letter says. 'On-call compensation must be introduced to recognize the time commitment and sacrifice required of field coroners.' Tom Grantham joined the service as a field coroner in 2016, and his territory includes 100 Mile House and Clinton, B.C. Grantham said he believes the job is an important community service, and he signed on with that mindset, and fulfilled it by working with families in times of grief after the death of a loved one. But he said the lack of pay, especially for on-call time, makes it hard to keep qualified and well-trained investigators on the job. He's on-call 24 hours a day, seven days a week, and when he's unavailable, he has to find his own replacement, Grantham said. 'If I want to go to somebody's birthday party and have a beer, then it is my responsibility to find another field corner who will take over my area,' he said. Grantham said a similar situation used to exist with ambulance attendants in the province, who weren't paid between calls until they were eventually given so-called standby pay. 'That's something that we don't have,' he said. Both Grantham and Chandi said they enjoy a level of relative security compared with some of their colleagues who may be 'nervous' about going public with their concerns. They said coroners are mostly unseen and the role they play in emergency services is misunderstood. 'The public has no idea what goes on,' Grantham said. 'They might watch television a little bit, kind of think of what a coroner is, but unless somebody dies within the family, they never get to meet or see or talk to a coroner. Maybe it's time that it was brought a little bit more out there.' This report by The Canadian Press was first published July 4, 2025. Darryl Greer, The Canadian Press
The Guardian
17-06-2025
- The Guardian
Hanging points death toll ‘unacceptable', attorney general Michelle Rowland says, urging states to review practices
Michelle Rowland has described the 'unacceptable' death toll linked to the continued presence of hanging points in Australian jails as 'deeply concerning' and told state and territory governments to 'review their practices'. The attorney general has also signalled she will push for accelerated justice reforms during upcoming meetings with her state and territory counterparts at the Standing Council of Attorneys-General forum. 'Every death in custody is a tragedy and the unacceptable number of deaths in custody caused by hanging points is deeply concerning,' a spokesperson for Rowland said. 'The attorney general strongly encourages state and territory governments to review their practices and continue to work toward effective solutions that ensure the safety and dignity of all Australians in the justice system.' A Guardian Australia investigation last week revealed 57 inmates have died in 19 separate prisons using hanging points that authorities knew about but failed to remove, often despite repeated suicides and stark warnings from coroners. At the Arthur Gorrie prison in Brisbane, the same ligature point – a set of exposed bars contained in older-style cells – has been used in 10 separate hanging deaths between 2001 and 2020, despite warnings to the state government as early as 2007 that it 'immediately' fund the removal of the bars. In one of those deaths in 2010, an inmate was sent into a cell containing the bars despite previously telling prison authorities that he had thought of using them to die by suicide, according to coronial findings. Sign up for Guardian Australia's breaking news email Similar failures were replicated across the state. At the Borallon prison, an inmate hanged himself from a similar set of exposed bars in 2011, five years after the Queensland government was told to 'immediately cover with mesh any bars accessible to prisoners in cells'. At the Townsville prison, two inmates hanged themselves from exposed bars a decade after the government was told to 'immediately' act on hanging points, 'including bars'. The situation was replicated in almost every state in the country. In New South Wales, the Guardian found 20 hangings from ligature points that were known to authorities but not removed. Another 14 deaths were identified in South Australia and seven in Western Australia. The failings have prompted urgent calls from experts and families of the dead for action, including on removing obvious hanging points, but also to improve mental health service delivery to jails. Most of the cases identified by the Guardian revealed failures in mental health treatment, risk assessment, cell placement or information sharing, including the death of Gavin Ellis, who died at Sydney's Silverwater prison complex in 2017. Ellis had a longstanding psychotic illness and had attempted to hang himself twice in his first three days of custody. Despite this, he was not seen by a mental health clinician for eight days, was not reviewed by a psychiatrist for six weeks, and was then sent into a cell with a ligature point that had been used by another inmate in the same unit of the prison two years earlier. 'The system does not have capital punishment, yet it leaves hanging points for inmates to use,' his mother, Cheryl Ellis, told the Guardian. State governments all said they were taking the issues of hanging points seriously, and had conducted long-term programs to make cells safe, as well as investing in better mental health assessment and treatment. Sign up to Breaking News Australia Get the most important news as it breaks after newsletter promotion Hanging deaths disproportionately affect Indigenous Australians, owing largely to the failure to decrease their overrepresentation in prison populations. In 2023, First Nations Australians accounted for 33% of the country's prison population – a record high – but just 3% of the overall population. On Tuesday, the former Labor senator Pat Dodson described the death toll using known ligature points as 'totally unacceptable'. Dodson worked on the royal commission into Aboriginal deaths in custody, which in 1991 told state and territory governments to remove hanging points and to enact strategies to reduce the incarceration rate for Indigenous Australians. He joined a group of crossbenchers, including David Pocock, David Shoebridge, Zali Steggall and Lidia Thorpe, in calling for national leadership on the issue. The Aboriginal and Torres Strait Islander social justice commissioner, Katie Kiss, said the removal of hanging points from prison cells to reduce self-harm was a 'key recommendation' from the 1991 royal commission. 'The failure to implement this and … other recommendations exacerbates the ongoing national shame that is Aboriginal deaths in custody,' she said. 'The treatment of our people, particularly when it comes to the administration of the justice system, is a deep stain on this country. They are being failed by an oppressive system that continues to deny their rights.' 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
News.com.au
10-06-2025
- News.com.au
Mum Jodie Carter shares agonising letters to bullied 12-year-old son Hamish after his suicide
Jodie Carter wishes she could have dragged the children who taunted and teased her 12-year-old son into the morgue to see his lifeless, bruised body so they could fully grasp the horrible reality of bullying. The Sydney mum makes no apologies for her brutal honesty, believing it's the only way children will ever really understand words can be deadly. 'The pain of seeing his little body at the coroners was indescribable,' she writes in her letters to her boy who died in December 2022 near his home in southern Sydney. 'I screamed and yelled and swore and cried. It just hurt so much. My beautiful little boy, lying on a hospital trolley. His arms covered because I know underneath them that he's all bruised and cut and broken.' Ms Carter wrote letters to her son Hamish every day for the first year after his passing. In them, she shares her most debilitating pain and her struggles to navigate the mundane reality of life without her son. 'It was helpful to me, as it felt like I was actually talking to him and was able to get some of my frustration and anger at losing him to of my system,' Ms Carter told 'I stopped after a year because it was hard going'. Sometimes they are almost impossible to read. Ms Carter hopes the diary entries – which now fill up several notebooks – will help others as much as they help her. 'I hope that one day I will find a way to use my letters to Hamish so that they raise awareness and stop another young child from being bullied,' she told 'I can't bring him back but I can fight for change. That's my calling now.' Ms Carter today shares extracts of her first six months of writing to her Darling Hamey. 20 December 2022 Tragedy, Hamey passed away yesterday. The worst thing I ever could imagine would happen ...we are devastated. I'm numb, empty, sad, angry. 21 December 2022 The pain of seeing his little body at the coroners was indescribable I screamed and yelled and swore and cried. It just hurt so much. My beautiful little boy lying on a f**king hospital trolley. His arms covered because I know underneath them that he's all bruised and cut and broken. There was blood on his head and a big hole in his skull and his head was soaked and stiff from the blood. His lips were blue and bruised. His little hands were all cut. Bruises and abrasions on each side of his face. My little darling. I thought I saw his eye start to open and I was just imagining it. I kept calling his name Hamey, Hamey, Hamey. He didn't want to die. I know he didn't want to die. Those kids pushed him and they will live a very hard life for what they have done. I want them to see what they have done to my beautiful little boy. See how hurt he was and that he spent a night in the cold in the bush, and I don't know if he died straight away or if he died slowly and painfully while I was sleeping not 50 mtrs up the road and unaware. I feel so guilty for not being there to save him and not stopping him. We went to bed at 10pm ish and he walked down the stairs towards me. The last thing I got to say to him was 'do you think your taller than me?' He stepped down to my level and I said 'not quite buddy' and gave him a hug. He just stood there and I said 'hug me back Hame' He patted me on the back. I'm pretty sure and I really hope that I kissed him on the forehead and said I love you. Then I went to bed and said 'don't stay up too late' then the nightmare began. Christmas Day 2022 Its been 6 days since Hamey passed. Our first Christmas without him and so soon after he left us. Its been a sad, but OK day. We opened all the presents he had given us and also opened his presents. He got lots of PS5 stuff. Headphones and games and memorabilia. We will set up as part of a shrine for him of his cool stuff. We didn't eat any usual Christmas food, just the fruit and some nibbles we already had here. Todd asked Barney if he would take Hamish's coffin on the Harley side car like a bikie funeral. We all think its pretty cool and would be happy for that to happen to get him to the church. Steve, Todd and Phil may ride their bikes in with him as a motorcade. We all think he will love it as he really enjoyed going on the bikes with Steve when they did their big ride. We all had a few tears this morning. Steve and I have been chatting to Hamey. When we finished opening the presents the lights flickered. I believe it was Hamish. 28 December 2022 Yesterday was pretty hard. You kind of float around just trying not to feel anything. Then visitors turn up and you are distracted for a bit. I woke up yesterday absolutely soaked in sweat. I had to wash all my doonah and mattress protector, pillows, everything was awful. In the afternoon Kam, Mya and I sat on the lounge and coloured in and read etc. I was trying to think of things for Ham's end of life celebration. Some funny, meaningful memories. I started to look at photos and both Kam and I just cried and cried. He was and is so little and so cute. There was so much life to live and I'm angry and devastated at his loss, why, why, why. I just want him back. 31 December 2022 The last day of the year. I don't even know how to describe what I'm feeling. I dreamt about Hamish this morning. We were at a toy shop. He found something he liked and opened it up and was showing it to me. That is all I remember. I just feel sad. We have been at Steve's for 3 days now with the dogs. Its time to go home. We have to take Hamish's clothes to the funeral home today. That is upsetting too. I know I want to put him in his hoodie and trackies. I'm struggling writing his eulogy. He was so little and I want to write positive things, but keep thinking of sad things. I also keep seeing him looking at me on the Sunday the day before. He came down to see me and just looked at me with this sad face. Why didn't I grab him and hug him and hold him tight and tell him how much I loved him. Instead I said 'Whats up Buddy' and he said 'F**k you' and walked away. What the hell did I do so wrong. Reading through all the emails I sent to the police. I said so many times about how sad he was and I did take him to counselling but I didn't take him to the doctors. He said he didn't need medication, he was fine. So now I have this huge guilt feeling. How will that ever go away? 1 January 2023 Michael the celebrant came today to talk to us through Hamish's service. He is lovely and it was very helpful to have him explain the whole process so patiently. I have taken lots of notes and now Kam and Cha and I have some focus on what needs to be done. Kam is writing a speech now and Charli wants to write one too. The hard part now is getting the right song. (we ended up selecting 'Free Bird' by Lynyrd Skynyd for him to be carried in with. Then 'Wish You Were Here' Pink Floyd and the 'Little Wonders' song by Rob Thomas that always made us all cry when we watched the Movie ' Meet the Robinsons, that Hamish loved so much'. The song to carry him out too was 'Nothing else matters' by Metallica. That's exactly how we felt. 3 January 2023 We visited Hamish at the funeral home … I held his hands, they were so cold to touch. My hands eventually warmed his. He didn't really look like himself. His face had bruises. His little nose was bruised and his forehead. His hair was really soft. He had his hoodie on. His little hands were crossed over his belly. We gave him some notes and stayed with him for a while. I gave him a mug and some hot chocolate and marshmallows and his sunglasses and his dream catcher and a soft monkey and soft dog. It was very sad. I kissed his forehead and put my forehead on his. It was so cold I watched the candle flickering and hoped it was a sign from him. 13 January 2023 Today was a hard day. I woke up OK and I felt all right for a bit. The counsellors came today at 10am. We all got a bit teary talking to them about our story. We had to take Charli to work and I made Kam go with me as Cha wanted to go to Big W. I kept my eyes down and felt instantly sad when we walked in. All the back to school stuff was out and it hurt thinking that I wont be getting. 18th January 2023 Dear Hamey, Today Kam and I picked up your ashes from Woronora Crematorium it was quite surreal. Yet another thing we had to face up to doing that we just don't want to do. Not want to as in we don't want to collect your ashes Hamish, we want you. We want you more than anything. We are all so devastated by you leaving us. Love Mum xxxxx 25 January 2023 Darling Hamey, its been a hard couple of days for all of us. Yesterday I spent half the day in tears. I had to collect your death certificate from the post office. The cause of death it said was multiple injuries. What parent ever wants to read that! Love Mum xxxx 26th January 2023 Dear Hamey, it was Australia Day today. Super hot and our aircon has broken down. Its getting fixed next weekend. Kammy and I had a few tears this morning. Kam dreamt about you, so she woke up sad. She said it was a nice dream though. Lots of love Mum xxxx 30 January 2023 Dear Hamey, tonight Kam, Cha and Mya and I had to go through the list of places to visit for tours for our big Europe trip. You know, you're coming too. We are taking your ashes or some of them so we can sprinkle you around a bit so you still get to go to the places I wanted you to visit. Ireland, London, Rome, Greece and Disneyland Paris and some cool theme parks that Kam has selected for you in Dubai. Perhaps we will put some of your ashes in a satchel or locket so we can just carry you around as well as leaving some for you to enjoy those places. I have to reply to Andy the detective tomorrow he has given us another update on their research and he says bullying did contribute to your passing. Which makes me so sad and angry. We will work to getting some sort of laws in your honour Hamey. We miss you darling. Lots of love Mum xxxxx 4th Feb 2023 Dear Hamey, Hi darling. I miss you heaps!!!. We had the aircon installed today. It works really well and you would love it. The man wanted to check the air in your room and he asked if anyone was in there. I said no you can go in. He still knocked at your door before he entered and I said 'its OK there is no one in there' which must makes me feel ill that you're not here. Its like the movies where no one touches the room of the child who died. Its exactly as you left it. I was looking for a frame today for your photo that we had on the mantle. I found the frames and some photos of you at preschool. That made me so sad. You are such a gorgeous boy, so spunky and I'm devastated, heartbroken you are not here. I'm just existing at the moment. Going through the motions and still loving your sisters. I would do anything to have you back. We all miss you darling Love mum xxxxxxx 8 February 2023 Dear Hamey, I've had too much to drink tonight. I'm sure you would have the shits with me. When I drove into work this morning I drove past a tall skinny boy in trackies like yours and he just looked like you and I started to cry and had to breathe. Like really breathe to pull myself together to get to work. Got through the day and the second I got in the car Guns N Roses came on 'Sweet Child O Mine' and I was crying again and couldn't stop and just cried all the way home. When I got home Mr Meagher had left your art folder at the front door. So I looked through that and cried again. Said hi to Charli and kept crying. Went out to water the garden and cried. Kam came home and I cried. So a shit night and I drank lots of wine. Cooked a shit dinner and watched a shit show on telly and I'm in bed now. Hopefully I'll sleep better cos I'm so tired. I miss you darling. Love Mum xxxxxx 15 February 2023 Dear Hamey Smoo, its your birthday tomorrow. The girls and I have been feeling pretty sad today thinking about it. What a strange and upsetting thing to go through. I keep seeing your gorgeous smile. I still walk up the stairs everyday and look in the PlayStation room for you. Your door is always closed and I try to rush past and not look at it or think about it too much. I still have a pile of your clean clothes in my bedroom that I cant really bring myself to do anything with. I don't really like being upstairs much. I only really come up to say goodnight to the girls and sleep. Then I'm running away. Kam and I had a few drinks tonight and Cha and the dogs hung out while we watered the garden. We all miss you, we are all sad. We will go up to dads in the morning and go on the ride and celebrate or rather commemorate your birthday. We love you and miss you so much darling. Lots of love mum xxxxxxx 18 March 2023 Darling Hamey, hi baby. Shit tomorrow is 3 months since you have passed. Well since we found out. According to the coroner you died before midnight on the 18th December. F**k Hamish, f**k f**k f**k I'm so f**king shitty about this whole thing. That bloody friend of yours that never told anyone. I wonder how she is feeling now. How are they all feeling? Little shits. 1 April 2023 Darling Hamey, a pinch and a punch for the 1st of the month. Oh boy how did this happen. 1⁄4 of the year is gone already. You have been gone for 3 months and 12 days. Its not been easy my darling boy. I took the dogs for a walk today. It was so much cooler, so we went a bit further than usual. My light is flickering beside my bed. I've been watching a thing on You Tube about signs from Angels. One of them is lights flickering. So I'm going to assume it's a message from you. What I was going to tell you was that I went down to your memorial again today. I didn't cry this time though. I was very calm. Some little birds flew over to say hello and pottered around in the top of the tree. I was thinking I should bring you something. Like the movie Under the Tuscan Sun and the old man takes flowers everyday to a memorial. Anyway I'm pretty sure you haven't seen that movie. I must make the girls watch it before we go away. Hamey darling please can you help bring me a miracle so we can go away. At the moment it feels like such an effort to get the money. I pray things will turn around soon and we can move forward. I miss you darling. Lots of love mum xxxxxxx 5 April 2023 Darling Hamey, hi my little precious. Did you come grocery shopping with me and the girls tonight? I hadn't really done a proper grocery shop with a trolley at Aldi in weeks/months it feels. When we were packing the bags at the car I had this pang of sadness of you and that here we are just shopping and packing the car and there is nothing in there for you. None of your cheese pizzas or chip snacks. You wont be home when we get home and I'm yelling at you to come down and help unload the car and show you what we got for you. Such a weird feeling Hamey. When you catch yourself doing something normal and you're going with the flow and then you realise your not there. Its really upsetting. 23 April 2023 Darling Hamey, hi baby it's Sunday night. I finally finished my statement for Andy today and emailed it through. I held it together for ages and was very mature about the whole thing. Removing my nasty remarks and blame and swear words. Basically it came down to you being bullied all those years and the damage it did to you and building up over the years. I wish I had taken you out of school. I wish I had taken you to different counsellors or psychologists and most of all I wish you were still here. I still think (name removed) should have handled the situation better and not put you in with the bullies and instead protected you more. Instead of thinking you were a trouble maker. Anyway I have sent it off now and I will follow up with Andy during the week. I also typed up quite a few more of my letters to you. I'm getting quite a collection together. It's hard reading back through them. They do make me cry. I miss you so much darling. Lots of love mum xxxxxxxxx 13th May 2023 Darling Hamey, hi baby. It my first Mother's Day without you tomorrow. You know what I thought I will wear my bracelet that has the little angel message on it from you. So that was comforting I had something special. Today I was trying to find Kamryn's birth certificate as Gada needs it to cancel our holiday to Europe. So sad anyway I couldn't find her birth cert. I was looking everywhere for it. Which lead me to finding more of your things. So that's quite lovely as I now have a cute little note I found from you that says 'Dear Mum, I love you, from Hamish' and it has a lovely drawing you did of you and me. So that was such a nice find and I have stuck it up on my desk. I also then found your hair from your first haircut and the little umbilical clip they put on you when you were first born. It was in your baby health book – which I never even filled anything in. 15 June 2023 Darling Hamey, gorgeous boy!! I wonder what your doing. Tonight I got home an came up to my bedroom to change into my daggy trackies so I could cuddle the dogs. I noticed your sheep that is in my room was on the floor. I'm sure he was sitting on the chair this morning. I wonder how he moved. Was it you? Maybe I should ask Charli and see if it was her. 18th June 2023 Darling Hamey, hi baby. Its been a really sad day today. It's 6 months since you left us. Which has brought up intense memories and sadness all day. I have pretty much cried all day and now again thinking of you and just feeling awful. I took the dogs to your memorial again and we stood there for a while and looked out. My heart actually hurt Hamey. I could feel it aching. Missing you and loving you so much and wanting you back so badly darling. Man it f**king hurts so much. Its like I'm just re-living everything and its so painful. I was trying to think of an excuse for something to say tomorrow at work when we talk about the weekend or just what's on our mind, because I don't want to say its 6 months since you went away because I will start crying again and feel terrible. I'll get through the day and come home and feel sad again then no doubt. F**king hell darling, so much to deal with and feel sad about. I would do anything to have you back Hamey. I miss you so much. Lots of love mum xxxxxxxx 19th June 2023 Darling Hamey, well that's it Hame another f**ked up milestone. 6 months to the date we found you had left us. The coroner said you had passed before midnight on the 18th. Even writing that sentence makes me feel sick Hamish. Just sick and sad and it hurts. Today Andy sent a note to say he is about to submit your report to the coroner. I reminded him it was 6 months today and he said he couldn't imagine how we must feel as it had been challenging for him to write the report and he had to give himself breaks away from it. I think I have a headache now. I want to see the report. Then its just going to bring it all flooding back again. When I write to you its just day by day. Having to go back through everything is heart wrenching. I know this because I have been putting off typing up your story from the notebooks and now I'm going to be weeks behind. I will have to make an effort to do that Hamey.
The Guardian
09-06-2025
- The Guardian
‘Astounding' negligence revealed: governments turn blind eye to staggering prison death toll
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. Sign up for Guardian Australia's breaking news email 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. Sign up to Breaking News Australia Get the most important news as it breaks after newsletter promotion 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
