Warning: This article contains content that may be distressing to some readers, including descriptions of self-harm and suicidal ideation.

An Aboriginal woman with a history of trauma and mental health struggles was pepper-sprayed by correctional officers during a self-harm incident at an ACT prison before not being assessed by a medical officer until the following day.

The review, conducted by the ACT Inspector of Custodial Services into the July 2025 incident, found the response at the Alexander Maconochie Centre had "both a significant immediate physical impact" on the woman in her 30s, "as well as a (potentially longer term) traumatic impact on her mental health".

The woman, referred to as Detained Person A, had been experiencing "considerable mental health distress" in the days leading up to the incident.

"This was compounded by an onerous discipline of 28 days separate confinement (isolation) and loss of privileges as a consequence of her climbing on a roof in protest for being unable to attend NAIDOC celebrations at the jail, an event of cultural significance," the review said.

On July 24, the woman was denied access to an Aboriginal art program because of her disciplinary status. Shortly afterwards, she engaged in what the review described as "serious self-harming behaviour".

Correctional officers responded by initiating a Code Black, a security response, rather than a Code Blue medical emergency response. As a result, health staff were not automatically alerted to the incident.

When officers entered the woman's cell, they deployed OC spray. The review found she briefly lost consciousness after falling to the ground.

Despite the circumstances, no ambulance was called.

The woman was then escorted by 14 officers to the Crisis Support Unit without receiving a health assessment and was not seen by a Justice Health Medical Officer until the next day.

History of trauma and mental health concerns

The review found the woman had experienced three acute mental health episodes in the weeks before the incident and had been identified as being at risk of serious self-harm.

It documented a "significant pattern of deteriorating mental health, emotional distress, repeated threats of self-harm, and several self-harm incidents" following her admission to the prison.

According to the review, the woman had experienced "a profoundly disadvantaged childhood and complex trauma, which has contributed to poor mental health and substance use".

Having entered out-of-home care at an early age, she was exposed to substance use, domestic violence, neglect and maltreatment, sexual abuse, disrupted education and homelessness.

Whilst the review did not identify any "overtly racist or directly discriminatory words, actions or policies" in the incident, it noted the "cumulative effect of custodial system design, institutional practices, and likely unconscious bias in decision making significantly impacted her as an Aboriginal woman, particularly given her serious and enduring mental health presentations".

These included the denial of the woman's request to attend the NAIDOC day celebrations, which the review labelled a "grossly disproportionate discipline punishment that removed opportunities for access to cultural and peer support," and the prison engaging in "culturally inappropriate" behaviour by placing her in proximity to men in the crisis support unit.

"The review saw examples of some staff interpreting her distress as her 'just being difficult' or being manipulative, which was perceived as requiring a security response rather than a therapeutic one," it said.

"In the Inspector's view, the incident reflects systemic and institutional racism, and likely unconscious bias in decision making and should guide ACTCS [ACT Corrective Services] in its efforts to address these factors."

Review recommends reforms

The review made 11 findings and four recommendations aimed at improving therapeutic responses to self-harm and increasing access to culturally appropriate support for detainees.

It found staff activated a Code Black rather than a Code Blue, resulting in up to 19 correctional officers attending the incident. The review concluded the response was inconsistent with best-practice approaches to self-harm.

The report also found the use of OC spray in the circumstances posed a "significant risk of physical and psychological harm and trauma".

"While the use of OC spray to respond to a detained person who is self-harming is not explicitly proscribed by policy or training materials, this review finds it should be," it said.

"Instead, a trauma-informed approach should be prioritised and articulated in policy, training and practices, including de-escalation and physical intervention only to the extent required to stop the harm."

Among its recommendations, the report called on ACT Corrective Services to strengthen its trauma-informed response to serious self-harm incidents within six months and providing additional trauma-informed training for staff.

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