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A perfect storm of errors meant Darren was placed in an unsafe cell. He died two days later
A perfect storm of errors meant Darren was placed in an unsafe cell. He died two days later

The Guardian

time13-06-2025

  • The Guardian

A perfect storm of errors meant Darren was placed in an unsafe cell. He died two days later

Warning: this story contains descriptions of self-harm and some readers might find it distressing. When Darren Brandon was detained at Melbourne assessment prison, a perfect storm of missed paperwork and a lack of clear intake procedure between police and the jail meant he was assessed as being low risk of self-harm. This could not have been further from the truth, according to his brother Steve. Darren lived with a serious brain injury after a motorcycle accident. It had left him with memory problems and bouts of depression. The family home where he lived had been sold after the death of his mother and Darren was between accommodation. 'Everything in our family just went upside down,' Steve tells Guardian Australia. In June 2018, when he found out Darren had been picked up by police, Steve says he and his father thought, 'Look, at least he's safe. He's not sleeping in his car on the street somewhere. He's safe. He's in care.' But the 51-year-old was placed in a cell with a known hanging point and self-harmed the next morning. He died in hospital two days later. Darren's death is one of at least 57 across 19 Australian prisons from hanging points that were known to prison authorities but not removed, as revealed by a Guardian Australia investigation. But his story also exemplifies what experts say is the broader story behind Australia's hanging cells crisis. None of the 248 deaths examined by the Guardian could merely be blamed on the presence of a ligature point. In most cases, those prisoners' placement in an unsafe cell was just the final failure in a litany of them. Sign up for Guardian Australia's breaking news email The investigation has also revealed repeated failures to properly assess, review or treat inmates with mental ill health, meaning their suicide risk was either missed or not properly mitigated. Of the 57 deaths, Guardian Australia has identified 31 cases where inmates who had been previously deemed at risk of suicide were sent into cells with known hanging points. There were 13 cases where inmates who had previously attempted self-harm in custody were sent into such cells. 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. In one 2018 New South Wales case an inmate known only as GS had warned officers he wished to kill himself, begged for psychiatric review for months, and was placed into a cell at Goulburn jail with a hanging point that had been used in five previous hanging deaths. That ligature point has since been covered. In another, an inmate assessed as having a high chronic risk of self-harm, and who had attempted suicide months earlier, in 2007 was placed into a cell at Sydney's Long Bay jail with what a coroner described as an 'obvious hanging point'. Staff at Arthur Gorrie correctional centre in Brisbane were told that an inmate had 'expressed an intention to commit suicide by hanging if the opportunity arose'. In October 2007 that inmate was placed into a medical unit that contained an obvious hanging point that had been used by another inmate in an attempted suicide just two months earlier. The hanging point was allowed to remain, despite one guard telling his superiors it needed 'urgent attention before we do have a suicide hanging'. The overwhelming majority of hangings from known ligatures points involved inmates on remand. Thirty-six of the 57 inmates were on remand, or awaiting trial or sentencing, which is known to be a time of elevated risk for mental ill health. Most people who experience incarceration have mental health problems but investment in prison mental health care is 'woefully inadequate', according to Stuart Kinner, the head of the Justice Health Group at Curtin University and the Murdoch Children's Research Institute. The fact that prisoners do not have access to Medicare 'is a somewhat perverse situation', Kinner says. 'We have a system that concentrates a very high burden of mental health issues and simultaneously almost uniquely excludes those people from a key source of funding for mental health care.' It is unlikely that Australia will ever be able to make all areas in all prisons 'ligature free', he says. 'Therefore, we don't just prevent suicide by removing ligatures, we prevent suicide by providing care and connection.' Ed Petch led the State Forensic Mental Health Service in Western Australia before returning to clinical work as a psychiatrist in Hakea – the state's main remand prison. He says that while the removal of known ligature points is important, improving access to health services should be the primary focus, in and out of prison. 'We had more mentally ill people in the prison than Graylands hospital,' he says, referring to the state's main mental health hospital. It has 109 beds. Hakea housed 1,143 men in mid-2024. Between 2018 and 2023, Petch says he saw more than 12 people every day. 'They weren't adequate mental health evaluations,' he says. 'It was quick in, see what the people are like, decide what treatment to give them and see them in a few weeks' time, if I was lucky. 'The rate of mental illness – acute mental illness and psychosis and depression and loads of mental health disorders – was absolutely vast.' A scathing report published in February by WA's Office of the Inspector of Custodial Services emphasised that Hakea is overcapacity and a prison in crisis. After a 2024 visit, the inspector, Eamon Ryan, formed a view that prisoners in Hakea were being treated 'in a manner that was cruel, inhuman, or degrading' and noted suicides, suicide attempts and assaults. There were 13 attempted suicides in the first quarter of that year, the same number as took place in the whole of 2023. Physical and mental health services 'were overwhelmed', with a nurse-to-prisoner ratio of approximately one to 86, and only three full time-equivalent psychiatrist positions for the state's entire prison system. Sign up to Breaking News Australia Get the most important news as it breaks after newsletter promotion Often the most severely mentally ill people are swept up by police, Petch says. 'The courts can't send them to hospital because they are full – or too disturbed – and cannot release them to no address or back to the streets so have no option but to remand them into custody where it's assumed they'll get the care they need. But that assumption is quite often false.' The WA Department of Justice said it was 'expanding the range of services provided to meet the needs of an increased prisoner population, including those with complex mental health issues'. This includes 36 beds in a new mental health support unit. A statewide program to remove ligature points had been running since 2005, a spokesperson said. Experts largely agree that a focus on hanging points, at the expense of all other problems, would be dangerous. Programs to modify cell design are expensive and can leave rooms inhospitable and cold, something that in turn may cause a deterioration in inmates' mental health. But Neil Morgan, a former WA inspector of custodial services, says a balance must be struck. 'I came across examples where changes were being made to cells … where the new beds were riddled with hanging points,' he says. 'Now that struck me as absolutely ludicrous in this day and age. Changes were only made after I raised my concerns.' Darren Brandon was a brilliant mechanic before his brain injury, Steve says. He had a coffee machine at his workshop and loved to host visitors and chat. 'He worked on Porsches and BMWs, all the high-end stuff,' he says. 'But he could work on anything.' But the motorbike accident hit him hard. The coroner noted his repeated attempts at suicide and self-harm. 'The up and down, the depression – this was the side-effects of his brain injury,' Steve says. '[Some days] he could go back to being like a standup comedian. I mean, he was so sharp and just witty and funny.' After the family home was sold, Darren began a residential rehabilitation program but left, and was reported to police as a missing person. When he went to a police station accompanied by a case manager, he was taken into custody due to a missed court date. Prison staff were not fully aware of his history of self-harm. This meant he was given a lower risk rating and was placed in a unit with a known hanging point and which was not under hourly observation. The coroner overseeing the inquest found that the design of Darren's cell was the 'proximate cause' of his death. He wrote that the 'rail inside the cell was known to be a ligature point well prior to Darren's death'. A spokesperson for Victoria's Department of Justice and Community Safety said the state's prisons had strong measures in place to reduce self-harm and suicide, including the use of on-site specialist mental health staff and training in the identification of at-risk inmates. Inmates are now required to undergo a mental health risk assessment within 24 hours of arriving in custody and are seen by a mental health professional within two hours of being identified at risk of self-harm. The state government has aimed to build all new cells in accordance with safer design principles for more than 20 years. 'The Victorian Government continues to invest in modern prison facilities to improve the rehabilitation and safety of people in custody,' the spokesperson said. Steve and his wife, Annie, keep a photo of Darren on their fridge. There are so many what-ifs. So many moments when something could have gone differently. 'If he'd been assessed properly, they would have said, 'Oh, this guy's had some attempts in the past, brain injury … OK, let's put him in a safer spot where there's no ligature points,'' Steve says. 'He'd still be alive.' Annie says: 'The system certainly failed him, and us as a family.' In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at

Prison cells made permanent to ease 'crisis'
Prison cells made permanent to ease 'crisis'

BBC News

time11-06-2025

  • Politics
  • BBC News

Prison cells made permanent to ease 'crisis'

Sixty-six temporary prisoner cells in Surrey have been made permanent in an effort to "ease" a crisis facing the prison prison population has doubled in the past 30 years nationally, while only 500 new cells have been built in the past 14 years, reports the Local Democracy Reporting Service (LDRS). The prison service is looking for short-term ways to increase capacity until four new prisons come online by 2031, creating 14,000 extra 66 cells at HMP Coldingley in Bisley were approved unanimously by Surrey Heath Borough Council on 6 June. There were no questions or debate from councillors during the two-minute item, according to the LDRS. The cells were installed during the COVID-19 pandemic to allow for safeguarding measures to be implemented.

Overcrowded and overlooked: Lebanon's prisons at breaking point
Overcrowded and overlooked: Lebanon's prisons at breaking point

LBCI

time04-06-2025

  • Politics
  • LBCI

Overcrowded and overlooked: Lebanon's prisons at breaking point

Report by Mirna Daou, English adaptation by Yasmine Jaroudi Lebanon's prison system is reaching a breaking point, with overcrowding escalating into a full-blown crisis. Despite mounting pressure, state efforts to address the situation remain sluggish, even as conditions inside detention facilities deteriorate and the financial burden on the government grows. Roumieh Prison, the country's largest and most overcrowded facility, has resumed court hearings, with three exceptional criminal chambers now holding sessions weekly on Tuesdays, Wednesdays, and Thursdays. A major contributor to the prison congestion is the high number of incarcerated Syrians. According to the latest figures from the Internal Security Forces (ISF), 1,698 Syrian nationals are currently detained in Lebanese prisons, including individuals accused of terrorism-related offenses. Of these, 1,076 have received final verdicts, while the remaining 622 are still awaiting trial. However, the exact number involved in major crimes remains unclear due to delays in completing a full classification of the detainees. A recent meeting between Lebanese Prime Minister Nawaf Salam and Syrian Foreign Minister Asaad Al-Shibani yielded promises of cooperation, specifically regarding the potential repatriation of Syrian prisoners. Yet, so far, no tangible progress has been made. Key obstacles include the absence of a formal legal framework between Beirut and Damascus, which is necessary to initiate transfers and clarify exceptions for certain cases. Under discussion are potential legal exclusions for prisoners convicted of serious crimes, but those convicted of offenses such as theft or illegal entry are expected to be returned to Syria to serve the remainder of their sentences. This paralysis raises concerns about whether the delay is due to legitimate legal challenges or simply a reflection of the institutional inefficiency that frequently stalls progress in Lebanon. With Syrian detainees comprising roughly 28% of the entire prison population, the consequences of continued inaction are dire, and the strain on Lebanon's penal system shows no sign of easing anytime soon.

John Major: It's time our punishments moved beyond prison
John Major: It's time our punishments moved beyond prison

Times

time17-05-2025

  • Politics
  • Times

John Major: It's time our punishments moved beyond prison

Our prisons are in crisis. They are overcrowded, violent and failing to rehabilitate offenders. Last July, the government was compelled to announce the emergency release of prisoners because the prison population was about to exceed the number of prison places. The consequence of not taking action would have been the collapse of the justice system. However, notwithstanding these measures, the Ministry of Justice revealed last week that, by November, it is expected there will be no more space for adult male offenders. We cannot go on like this. This state of affairs has been caused by a prison population that has grown beyond any expectation over recent decades, and that growth is forecast to continue. Early in my political career, I was a parliamentary

Call me sexist but prison is no place for a woman
Call me sexist but prison is no place for a woman

Telegraph

time16-05-2025

  • Politics
  • Telegraph

Call me sexist but prison is no place for a woman

It's surely a surprise to precisely no one that Britain's prisons are in crisis. They have been, on and off, for well over a decade. That's not to diminish the seriousness of the situation, but it's a reflection of an inexcusable lack of planning by the last Conservative government. In 2016, Theresa May promised to build 10,000 new prison places. Three years later her successor Johnson bumptiously pledged another 10,000 new prison places by 2026. So far, just 6,000 new places have resulted since 2019. The reason jails are overcrowded are manifold and include the fact that more offenders are being sent to prison and a sclerotic judicial system that sees 17,000 prisoners on remand, which is the highest level for at least 50 years. As of April there were 84,043 male prisoners and 3,683 female prisoners in England and Wales. With space rapidly running out, Labour is introducing emergency measures that will release thousands of inmates early – those offenders with sentences between one and four years, who have been released after serving their minimum period but then recalled for breaching their licence, such as by not sticking to their curfew, will be released after just 28 days. It will include criminals convicted of assault, burglary, theft, fraud, drug dealing and some domestic abusers. That doesn't sound like justice to me. So here's a solution; release women prisoners. Not all of them obviously; the Rose Wests, Beverley Allitts and Lucy Letbys must stay put and serve their time. But so few female inmates pose a danger to the public it seems nonsensical to keep them locked up when the men's estate is crying out for space and wardens to staff it. Two-thirds of female prisoners have committed non-violent offences and more than half – 57 per cent – of female prisoners are victims of domestic abuse. Self-harm in women's prisons is over eight times higher than in the male estate and, most salient of all, when mothers are sent to prison – an estimated 50 per cent of offenders – families are broken up with often lifelong consequences for the children.

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