Coroner: Young Inmate’s Death at Goulburn Prison Was ‘Unnecessary’

A New South Wales coroner says it is "extraordinary" that a "young, vulnerable" inmate was left alone for 18 hours before he was found dead in his prison cell.

Warning: This story contains references to suicide.

On Tuesday Deputy State Coroner Joan Baptie handed down her findings into the death of a 19-year-old, only identified as "Joel", at the Goulburn Correctional Centre in 2022.

He was found unresponsive in his single-bed cell on the morning of July 25.

Joel had been charged with a robbery while armed with a fishing knife in May 2022 and was on remand while his matter was before the courts.

In July he was moved into a two-bed cell at the Goulburn facility and on the 24th of that month he passed a small, handwritten note to a correctional officer requesting to be moved.

The 19-year-old was relocated to a one-bed cell the same day.

The inmate was not seen again until 8:30 the following morning, when he was found dead.

"Joel was left by himself for 18 hours without human contact or wellbeing observations by correctional officers," Magistrate Baptie said.

"It is quite extraordinary that young, vulnerable inmates are left for such lengthy periods of time without human contact."

‘Significant concern’

Goulburn Correctional Centre governor Leah Nicholson told the inquest that due to staffing and funding shortages officers could not conduct cell observations on inmates who were not declared at risk of self-harm.

Magistrate Baptie found that increased staffing levels and funding may have allowed Joel to be observed, but said that was predicated on him communicating concerns about his mental health.

She also found it "extraordinary" that inmates were served dinner at 2pm and were not provided with additional food until breakfast was delivered at 7am.

"Inmates are deprived of their liberty, however, [they] should not be exposed to unnecessary hardship and deprivation, including the timeliness of the provision of food," Magistrate Baptie said.

Joel was found to have died by suicide in his cell.

Magistrate Baptie noted that the Coroner’s Court had been advised "repeatedly" by Corrective Services NSW (CSNSW) areas of risk pertaining to self-harm in prisons were being addressed by a capital works program.

She said it was of "significant concern" that the infrastructure of the cell had permitted Joel to take his own life.

"It is also of concern that [the cell] has not been decommissioned, but is simply no longer operational at this time," Magistrate Baptie said.

Request for protection

Joel asked to be moved out of the two-bed cell because he feared for his safety.

The 19-year-old was concerned other inmates would find out that he had given police information about co-offenders allegedly involved in his crime.

He requested to be placed in a wing that provided greater protection, which required an officer to fill out an assessment application.

The application was not completed before Joel died.

Magistrate Baptie noted that it was unknown whether his placement in the higher-protection unit would have positively impacted his low mood.

She recommended CSNSW provide training to correctional officers about policies governing inmates’ requests to move cells.

Magistrate Baptie also recommended an assessment used to determine whether an inmate needed increased protection due to safety concerns be conducted within four hours of a request.

"[Joel] was a loyal and supportive friend and hardworking colleague," she said.

"Members of his family have been constant advocates for him and have been unwavering in their determination to ascertain the reasons for his unnecessary death."

CSNSW has been contacted for comment.