A coronial inquest heard on Thursday that vulnerable people are still being held in cells with hanging points in a New South Wales prison unit where an Aboriginal man took his life.
Proud Darkinjung man and father of two, Timothy Garner, died on 7 July 2018 while held on remand at the Metropolitan Remand and Reception Centre (MRRC) in Silverwater. He was 30 years old.
Mr Garner had a significant history of mental illness including diagnoses of bipolar disorder and schizophrenia.
An inquest into his death, presided over by Deputy State Coroner Derek Lee, heard about Mr Garner's troubled mental state prior and subsequent to his arrest; failure to complete mandatory training by some members of the Risk Intervention Team (RIT) who were tasked with reducing his risk of suicide; and difficulties faced by Mr Garner's family members when they attempted to alert the prison to his fragile mental state.
The inquest heard that Mr Garner's mental health continued to deteriorate in custody, even in the face of repeated pleas from his mother and partner that he needed acute mental health support.
Deputy State Coroner Derek Lee found on Thursday that Tim Garner took his own life using the fire sprinkler in his cell at the MRRC's Darcy Pod.
In hearings last year, the inquest received evidence that the Darcy Pod, an older section of the prison, is a stark environment, particularly for people struggling with their mental health.
Mr Lee noted that refurbishments to the Pod are currently taking place, including the removal of hanging points, but meanwhile some at-risk prisoners remain housed there.
His Honour recommended the Commissioner of Corrective Services monitor the ongoing refurbishments so that all inmates involved in the RIT process be housed in refurbished Darcy Pod units, or in the newer O Block, by the end of 2024.
His Honour also recommended that the Commissioner consider the introduction of refresher training for prison staff on Risk Intervention Teams at minimum 5-year intervals.
Mr Garner is one of at least 558 Aboriginal and Torres Strait Islander people who have died in custody and police operations since the Royal Commission into Aboriginal Deaths in Custody brought down its findings and recommendations in 1991.
The Aboriginal Legal Service (NSW/ACT) represented his mother, Michelle Garner, in the coronial inquest.
Ms Garner said her on "was let down by the system".
"Tim was a good dad to his two daughters. He had his family's backs and he had his mates' backs. He struggled with his mental health, but he really didn't have to die the way he did," she said.
"Tim was just 30 years old and had so much life left to live. His death could have been avoided if Silverwater listened to our repeated phone calls and gave him the appropriate healthcare.
"I don't want what happened to Tim swept under the carpet. Prisons are full of people with mental health issues and they deserve to get treatment. They should be treated like human beings. And for their families, they deserve to know when their loved one goes to jail, they'll be coming back out."
The inquest heard Mr Garner had been diagnosed with bipolar disorder and schizophrenia and was being seen by a specialist team to assess his risk of self-harm in the lead-up to his death.
In the week before he died, a psychiatrist recommended Mr Garner be transferred to a mental health facility, but five days before his death, he was removed from the waitlist and cleared from the "risk-intervention team's" assessment after his condition was deemed to have improved.
Deputy State Coroner Lee said it would have been more appropriate for Mr Garner to remain under the team's management after reviews carried out in June 2018.
"It would have allowed for Tim to be monitored and reviewed regularly and for any ongoing interventions to be facilitated," he said.
But Mr Lee found it was not possible to determine if ongoing risk intervention would have been "likely to materially alter subsequent events".
He said the time taken for Mr Garner to be reviewed by psychiatrists in May and June 2018 "did not conform with defined timeframes" and he was not adequately reviewed in the five-day period before his death.
"He was not in fact reviewed at all," Mr Lee said.
The coroner also noted the prison staff's communication with Mr Garner's family was a matter of "central importance".
"His mother continually called the prison to express her concern that Tim was acutely unwell, not taking his medication and not being treated properly," Mr Lee said.
ALS NSW/ACT Coronial and Trial Advocate Emma Parker said the ALS "stands with our client Michelle Garner and all of Tim Garner's family and friends"
"Gaols are not appropriate or therapeutic environments to treat mental health conditions," she said.
"Tim Garner should have been treated in a hospital, not in custody. His repeated self-harm attempts and debilitating mental illness were poorly understood by members of Silverwater's Risk Intervention Team.
"Tim's death is an injustice and yet another case where serious shortcomings in prison healthcare have been uncovered through an inquest."
Ms Parker said the case represented "further proof that NSW prisons are failing families and communities, especially Aboriginal people who are disproportionally locked up by our police and courts".
"It is unacceptable that preventable deaths are still occurring in NSW prisons. Last century the Royal Commission into Aboriginal Deaths in Custody raised the need to remove hanging points throughout prisons to prevent deaths in custody, yet Tim Garner tragically died 27 years after that recommendation was handed down," she said.
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