Sick on the In­side

Aus­tralia’s pris­ons have be­come de facto men­tal-health in­sti­tu­tions for our so­ci­ety’s sick­est and most vul­ner­a­ble. As the tragic case of David Wother­spoon proved, they are not cop­ing.

The Monthly (Australia) - - APRIL 2018 - A shock­ing new se­ries of deaths in cus­tody by Bron­wyn Ad­cock

Aus­tralia’s pris­ons are in­creas­ingly filled by peo­ple with men­tal ill­nesses.

Over the fi­nal few months of his life, 31-year-old David Wother­spoon, an in­mate at Cess­nock Cor­rec­tional Cen­tre in the Hunter Val­ley re­gion of New South Wales, in­creas­ingly be­lieved that prison of­fi­cers were plot­ting to kill him: poi­son­ing his food and send­ing toxic gas into his cell. To pro­tect him­self, he barely ate or slept, and armed him­self with a “shiv”, a sharp­ened screw­driver. In mid March 2013, after months of pri­vate tor­ment, he asked to see the men­tal-health nurse at the prison’s clinic. He was tired and drawn – he’d dropped 7 kilo­grams – and ag­i­tated. “I’m not sick, I know I am not sick,” Wother­spoon told her, con­tin­u­ally check­ing the door, watch­ing for prison of­fi­cers, wor­ry­ing he would be over­heard. He told her about the plot against him, and about his weapon. “Don’t be afraid, miss. I won’t be us­ing it on you. It’ll be for one of those ones who harms me.” Then he asked for help: he wanted to hand over his shiv and be trans­ferred to the Men­tal Health Screen­ing Unit (MHSU), a spe­cial­ist fa­cil­ity at Sil­ver­wa­ter Cor­rec­tional Com­plex in Syd­ney, “be­cause they will make me feel bet­ter”. Wother­spoon’s re­quest was prob­a­bly a brief flash of in­sight. He had a long his­tory of se­ri­ous men­tal ill­ness. He was schiz­o­phrenic, and had been in and out of psy­chi­atric hos­pi­tals for most of his adult­hood. When he was 29, and in an adult prison for the first time, he at­tempted sui­cide by cut­ting his throat with a sharp­ened tooth­brush, and was trans­ferred for treat­ment at the MHSU. After his dis­clo­sure to the nurse, he was moved to a cell in Cess­nock’s Men­tal Health Unit. This sep­a­rate wing of the fa­cil­ity, once used for seg­re­ga­tion, had re­cently been con­verted to house the in­creas­ing num­ber of men­tally ill in­mates pour­ing into the state’s pris­ons. The next day, March 15, Wother­spoon was seen by the unit’s psy­chi­a­trist, Dr Christo­pher Bench, who ob­served from prison records that Wother­spoon hadn’t been tak­ing his an­tipsy­chotic med­i­ca­tion for the past four months, but had been us­ing drugs il­lic­itly in prison – dan­ger­ous fuel for his ill­ness. Bench as­sessed that Wother­spoon was in the grip of acute psy­chosis, and was “de­com­pen­sat­ing” – a psy­chi­atric term de­scrib­ing a crit­i­cal men­tal deterioration. He im­me­di­ately re­ferred Wother­spoon to the MHSU fa­cil­ity at Sil­ver­wa­ter. Yet when Bench re­turned to work at Cess­nock five days later (his po­si­tion was only staffed for two days a week) Wother­spoon was still there. Bench wasn’t sur­prised: “It was not un­usual for such ur­gent cases to have to wait some time un­til a po­si­tion was avail­able at the MHSU,” he would later tell the coro­nial in­quiry. Wother­spoon was wait­ing in­side a “safe cell” – by def­i­ni­tion, one with con­stant CCTV mon­i­tor­ing and no hang­ing points. Here, in Cess­nock’s Men­tal Health Unit, it was common prac­tice for in­mates to be locked down for 23 hours a day, with lit­tle com­pany, fresh air or sun­light. Most days, a Risk In­ter­ven­tion Team (a nurse or doc­tor, and prison staff) checked on Wother­spoon, and ac­cord­ing to their notes his para­noia was un­re­lent­ing. He could see nee­dle marks where poi­son was be­ing in­jected into his food; some days he took his med­i­ca­tion, mostly he didn’t. He told a nurse he used the drug “ice” while in­side the unit. Ten days after he first reached out for help, still wait­ing, Wother­spoon self-harmed. He’d been ex­pect­ing a visit from his part­ner, Co­rina Ma­son, but she wasn’t al­lowed in, hav­ing ar­rived 15 min­utes late for visit­ing hours. Wother­spoon re­acted with hys­te­ria, slash­ing his arm with a shard of glass. For the next five days the lights in his cell were left on per­ma­nently. April ar­rived. Still Wother­spoon waited, his ill­ness rag­ing. He now thought prison of­fi­cers were go­ing to abduct him, then kill him. “The screws are try­ing to knock me, I heard them say it. They are go­ing to put me in the boot of the car and knock me,” he told Ma­son in a phone call that was recorded, and later tran­scribed. “I was sick last night, I never took my pills. I knocked on the door grille, put my hands out to say, ‘Knock me, knock me.’” He was des­per­ate for his trans­fer. “I’m sick, I need help and they are not mov­ing me. Can you ring up Sil­ver­wa­ter and see if I have a bed place­ment there?” he asked Ma­son. “I need peo­ple to talk to and they just leave us locked in the cell all day … I stayed up all night, I didn’t sleep or take my med­i­ca­tion … I need help, bubba …” On April 4, three weeks after he was re­ferred, a fax ar­rived at Cess­nock say­ing Wother­spoon had a bed at the MHSU. How­ever, by the time the fax was re­ceived and pro­cessed, the trans­port truck had left – and the next one was not due for two days. Wother­spoon was told he would be trans­ferred to the MHSU on April 6. At 3.06pm on April 5, the day be­fore he was due to leave, Wother­spoon be­gan throw­ing wads of wet toi­let pa­per at the se­cu­rity cam­era in­side his cell. At 3.14pm, he started again, this time par­tially cov­er­ing the lens. A cor­rec­tive ser­vices of­fi­cer was mon­i­tor­ing the CCTV sys­tem, but she didn’t no­tice what was hap­pen­ing. Wother­spoon took the shoelaces from his shoes and the cord from his pants. There was a hang­ing point in his cell – a bolt on the back of the door. He used it to hang him­self.

Aus­tralia’s pris­ons are in­creas­ingly filled by peo­ple with men­tal ill­nesses. The last na­tional sur­vey of prisoner health found that nearly half of all prison en­trants re­port be­ing di­ag­nosed with a men­tal-health dis­or­der. To

“Lay­ing on his deathbed, he was. Two screws next to him. Hand­cuffed to the bed.”

quan­tify this, there are 41,000 peo­ple in prison in Aus­tralia, but the “flow” pop­u­la­tion – the num­bers who spend time in prison or re­mand over the course of a year – is dou­ble that. This means around 40,000 peo­ple with men­tal ill­ness go through Aus­tralia’s prison sys­tems an­nu­ally. The rates of in­mates with more se­vere and dif­fi­cultto-treat con­di­tions – psy­chotic dis­or­ders like schizophre­nia – are widely es­ti­mated to be 10 to 15 times greater than those found in the gen­eral pop­u­la­tion. How­ever, a re­cent sur­vey of in­mates from four pris­ons in Western Aus­tralia found an even higher in­ci­dence: 20 per cent of fe­male in­mates had schizophre­nia or a re­lated dis­or­der, com­pared to just 0.35 per cent of women on the out­side. The same sur­vey found nearly half of all fe­male pris­on­ers and a quar­ter of male ones had at­tempted sui­cide at some point in their lives. While men­tal ill­ness doesn’t dis­crim­i­nate – it can af­fect any­one, re­gard­less of in­come or back­ground – in­car­cer­a­tion does. The men­tally ill who get locked up are usu­ally poor, have in­se­cure hous­ing, strug­gle with ad­dic­tion or a cog­ni­tive dis­abil­ity, and lack strong fam­ily net­works to keep them safe. As a group, they face higher rates of con­vic­tions for lower-level of­fences. “I’m no longer sur­prised by the num­ber of peo­ple with men­tal ill­ness I see who are in on very petty of­fences,” says Dr An­drew El­lis, a foren­sic psy­chi­a­trist and fel­low at the Royal Aus­tralian and New Zealand Col­lege of Psy­chi­a­trists, who also works in the NSW prison sys­tem. “If I had done [what they had], there is no way I would be in jail, be­cause I know a lot of lawyers, and I could post bail, and I’ve got a house I could go to. Th­ese peo­ple don’t have those kinds of re­sources.” Aus­tralia’s pris­ons have be­come de facto men­tal­health in­sti­tu­tions for our so­ci­ety’s sick­est and most vul­ner­a­ble, and right across the coun­try those who ex­am­ine and re­port on the qual­ity of this care are telling a sim­i­lar, alarm­ing story. “The sys­tem is strug­gling to keep pace with the men­tal health re­quire­ments of the in­mates,” says a re­port from the NSW In­spec­tor of Cus­to­dial Ser­vices. “With over­crowd­ing and the short­age of psy­chi­atric beds, pris­on­ers with men­tal health is­sues are at in­creased risk of self-harm and even death,” states the Vic­to­rian Om­buds­man. And, ac­cord­ing to the Western Aus­tralia In­spec­tor of Cus­to­dial Ser­vices, there are “in­ad­e­quate spe­cial­ist fa­cil­i­ties for pris­on­ers with men­tal im­pair­ment and men­tal health is­sues”. El­lis’s task of try­ing to pro­vide psy­chi­atric care in­side a re­gional NSW prison is an in­vid­i­ous one: he has a wait­list he can never get to the end of, and he’s forced to of­fer an in­fe­rior level of care. “I could not phys­i­cally see the num­ber of peo­ple that would ben­e­fit from see­ing a psy­chi­a­trist,” he says. “And the type of care that I would be able to give would be less than I am able to give in a hos­pi­tal set­ting. And many of the peo­ple, ow­ing to the sever­ity of their dis­or­der at the time, if they were in the com­mu­nity you would have them ad­mit­ted into a hos­pi­tal.” So do peo­ple fall through the cracks? I ask. “It is not re­ally a crack they have to fall through,” he says. “It’s a gap­ing chasm.” As with a quar­ter of all pris­on­ers in Aus­tralia, David Wother­spoon was Abo­rig­i­nal. He grew up in a small coastal town 80 kilo­me­tres east of Cess­nock. He was one of eight kids, and most of his fam­ily still live in the area. They found out that some­thing had hap­pened to David in prison after his sis­ter’s boyfriend over­heard on a po­lice scan­ner that he was be­ing rushed to hos­pi­tal. Wother­spoon had been found by two prison of­fi­cers who were de­liv­er­ing food to the cells. He was re­sus­ci­tated – with Dr Christo­pher Bench’s as­sis­tance – but once at hos­pi­tal was found to have ir­re­versible brain dam­age. He died 10 days later with­out ever re­gain­ing con­scious­ness. In late Au­gust of last year, the coro­nial find­ings into Wother­spoon’s death were handed down, and a month later I trav­elled to his home­town to meet his fa­ther. David Wother­spoon Se­nior, 63, was so thin that the bones of his face were vis­i­ble un­der his skin. He told me he’d lost around 24 kilo­grams over the past few years, due to grief from his son’s death, and stress from the slow un­fold­ing of the coro­nial process. Wother­spoon Se­nior hadn’t vis­ited his son in jail – he’d done his own time and wouldn’t step foot in­side the place again – but came to his hos­pi­tal bed­side. He said his son’s un­con­scious body was hand­cuffed. “Lay­ing on his deathbed, he was. Two screws next to him. Hand­cuffed to the bed. Shack­led and ev­ery­thing.” Cor­rec­tive Ser­vices NSW wouldn’t an­swer di­rectly when asked whether this oc­curred – only con­firm­ing that in­mates on “med­i­cal es­cort” can be re­strained. His fa­ther vis­ited as of­ten as he could – it’s just un­der an hour’s drive from his home – but the Wother­spoons are not a fam­ily of means. The day the doc­tor wanted to dis­cuss turn­ing off life sup­port, Wother­spoon Se­nior had no money for petrol. Cor­rec­tive Ser­vices NSW ar­ranged a fuel voucher the next day, and he re­turned to make the only pos­si­ble de­ci­sion. “I couldn’t go again there once they turned off the ma­chine,” he said. “That was it for me. I couldn’t sit there and hold his hand while he died.” Ac­cord­ing to his fa­ther, Wother­spoon was a “bit of a wild child”. He left school around Year 6, be­fore he could read or write, and soon started dab­bling in drugs. He left home barely into his teens, and ended up do­ing time in a ju­ve­nile prison in Tas­ma­nia. His men­tal­health prob­lems emerged in young adult­hood – at 22, he

at­tempted sui­cide in front of his dad, and spent the next three years in a psy­chi­atric hos­pi­tal. He re­ceived mul­ti­ple di­ag­noses: psy­chosis, drug­in­duced psy­chosis, schizophre­nia and an­ti­so­cial per­son­al­ity dis­or­der. Once he got out of hos­pi­tal, he was a con­stant client of com­mu­nity men­tal-health ser­vices. When he was well, he was tak­ing his med­i­ca­tion, paint­ing Abo­rig­i­nal art and talk­ing about open­ing up a gallery; when he wasn’t, he was us­ing drugs such as heroin and metham­phetamines, and end­ing up back in hos­pi­tal – an­other six short-term ad­mis­sions. Co­rina Ma­son, his part­ner, says he chased drugs to es­cape “the bad mem­o­ries he had from grow­ing up” – in par­tic­u­lar, ex­po­sure to fam­ily vi­o­lence. (His fa­ther dis­putes this ac­count.) Wother­spoon’s first ex­pe­ri­ence of adult prison, at 29, came just a week after his lat­est hos­pi­tal ad­mis­sion. He’d got into an ar­gu­ment over a $50 debt and stabbed a man. He’d been in­side for a month when he tried to com­mit sui­cide by cut­ting his throat. While he phys­i­cally re­cov­ered, he re­mained men­tally un­well for his en­tire nine months in re­mand, re­peat­edly re­port­ing that he was hear­ing voices – in­clud­ing on the day be­fore he at­tended his court hear­ing. When he was re­leased on bail he only lasted five months be­fore be­ing charged again, this time over an ag­gra­vated break and en­ter – dur­ing which noth­ing was stolen – and go­ing back to prison. With­out doubt, the man whom the state took into cus­tody – this fi­nal time – was se­verely men­tally ill. “What about their duty of care?” asks Wother­spoon Se­nior. “I want to know why they didn’t do their job. Why didn’t they pre­vent it?”

The coro­nial in­quest into the death of David Wother­spoon un­cov­ered a litany of er­rors and over­sights. The four thick files, con­tain­ing thou­sands of pages of ev­i­dence and now sit­ting in the ar­chives at the NSW State Coroner’s Court, also give a rare in­sight into what a prison sys­tem looks like when it’s strug­gling to meet the de­mands of car­ing for the men­tally ill. Wother­spoon re­turned to prison in April 2012, with his men­tal-health sta­tus and his­tory of self-harm clearly marked on his file. Con­sid­ered “at risk”, he was seen ap­prox­i­mately once a month by var­i­ous staff from the state govern­ment’s Jus­tice Health and Foren­sic Men­tal Health Net­work, which pro­vides health care in­side pris­ons. Read­ing through the notes of th­ese meet­ings is like watch­ing a car crash in slow mo­tion. In May 2012, he has symp­toms of para­noia; in June, au­di­tory hal­lu­ci­na­tions; in Au­gust, he re­fuses his an­tipsy­chotic in­jec­tion, re­lent­ing three days later; by Novem­ber, he’s ir­ri­ta­ble and con­sis­tently re­fus­ing his med­i­ca­tion; by early 2013, he’s off his med­i­ca­tion and deny­ing he’s sick. Wother­spoon then goes seven weeks with­out an ap­point­ment, but when seen again in March ad­mits to in­ject­ing buprenor­phine – an opi­ate sub­sti­tute – and us­ing ice.

Each week, 16 other in­mates were locked in prison cells around the state, all await­ing trans­fer, all in states of ex­treme men­tal dis­tress.

Wother­spoon’s men­tal un­spool­ing in­side prison was long and well doc­u­mented. Yet it wasn’t un­til he pre­sented him­self to the clinic in mid March, with his shiv and ram­pant para­noia, that a de­ci­sion was made to es­ca­late his care. Ac­cord­ing to the coroner, his “men­tal health de­te­ri­o­rated with­out suf­fi­ciently prompt and ac­tive in­ter­ven­tion”. Even once Dr Christo­pher Bench had iden­ti­fied Wother­spoon’s crit­i­cal state, it still took three weeks to gain a bed at Sil­ver­wa­ter’s MHSU. The con­sul­tant psy­chi­a­trist who re­viewed Wother­spoon’s care for the coroner put this down to the prob­lem of “ac­cess block” – in other words, too many men­tally ill peo­ple and not enough beds. At the time, the MHSU – a fa­cil­ity for male in­mates – had 43 beds serv­ing a statewide pop­u­la­tion of more than 9000 men. (There are still 43 beds at the MHSU, but the male prison pop­u­la­tion is now more than 12,000). De­cid­ing who gets th­ese sought-after beds must be a wicked prob­lem in­deed. Tucked away in one of the fold­ers of doc­u­ments sup­plied to the coro­nial in­quest was the wait­list for beds at the MHSU over the same three weeks when Wother­spoon was wait­ing. It reads like a roll­call of hor­ror. Each week, 16 other in­mates were locked in prison cells around New South Wales, all await­ing trans­fer, all in states of ex­treme men­tal dis­tress. Many were suf­fer­ing schizophre­nia with un­con­trolled psy­chosis, au­di­tory hal­lu­ci­na­tions and ter­ri­fy­ing delu­sions; one man had cut him­self with a ra­zor, and then tried to swal­low it; an­other was so se­verely de­pressed he was “ac­tively look­ing” for ways to com­mit sui­cide, and needed to be “watched at all times”. The in­quest un­cov­ered an­other, more pro­saic, rea­son for the de­lay in Wother­spoon’s trans­fer: the nec­es­sary pa­per­work wasn’t filled in un­til six days after Bench had re­ferred him. The nurse re­spon­si­ble couldn’t re­call why it took so long. How­ever, the enor­mous work­load faced by the prison’s health staff was ev­i­dent. The two men­tal-health nurses re­spon­si­ble for the 12 crit­i­cally ill in­mates in the Men­tal Health Unit at Cess­nock were fre­quently called away to deal with sick in­mates among the prison’s main­stream pop­u­la­tion of 800. Bench was see­ing 12 pa­tients, and re­view­ing hun­dreds of files ev­ery shift – a caseload he de­scribed as “in­ten­sive”. In­ad­e­quate staffing also played a role in the crit­i­cal over­sight made in the CCTV mon­i­tor­ing room the af­ter­noon of Wother­spoon’s sui­cide – as he be­gan throw­ing wads of toi­let pa­per at his cell cam­era. The cor­rec­tive ser­vices of­fi­cer who missed this was on her own, on her first ever shift in the mon­i­tor­ing room. She was re­spon­si­ble for keep­ing track of all the cells in the Men­tal Health Unit – dis­played as 64 sep­a­rate im­ages – plus other cam­era feeds from around the jail, while also tak­ing phone calls and an­swer­ing cell call-alarms from in­mates. Her train­ing was so min­i­mal that a cou­ple of hours ear­lier she’d been un­able to ac­ti­vate the elec­tronic locks to al­low an­other of­fi­cer fin­ish­ing his shift to leave. (Cor­rec­tive Ser­vices NSW has re­cently changed poli­cies and pro­ce­dures around the mon­i­tor­ing room.) Of all the cracks Wother­spoon fell through, the fi­nal and ul­ti­mately fa­tal one was the pres­ence of a hang­ing point in­side his “safe cell”. In the im­me­di­ate af­ter­math of his death, the Cor­rec­tive Ser­vices In­ves­ti­ga­tions Unit dis­cov­ered that all the cells in the Men­tal Health Unit had the same hang­ing point on the back of the door. (The doors have since been re­placed.) Such an over­sight ap­pears ex­tra­or­di­nary – when Wother­spoon hanged him­self, it was 22 years since the Royal Com­mis­sion into Abo­rig­i­nal Deaths in Cus­tody drew at­ten­tion to the need to screen hang­ing points in cells. How­ever, it’s an over­sight that con­tin­ues to oc­cur across the coun­try. A re­cent re­port from the Aus­tralian In­sti­tute of Crim­i­nol­ogy, ex­am­in­ing all deaths in cus­tody be­tween 1999 and 2013, found that the coroners in­volved made 33 sep­a­rate rec­om­men­da­tions about re­duc­ing hang­ing points, re­mind­ing prison sys­tems – again and again – about the need to en­sure com­pli­ance with “safe cell” prin­ci­ples. Last year, while in­ves­ti­gat­ing two deaths by hang­ing, the North­ern Ter­ri­tory coroner said it “beg­gars be­lief that a prison de­signed and con­structed in the 21st cen­tury has such clas­sic hang­ing points with no mit­i­ga­tion of that risk”.

The coroner in­ves­ti­gat­ing Wother­spoon’s death, Mag­is­trate Michael Barnes, did not as­sign blame to any of the in­di­vid­u­als who tried to care for him in his fi­nal days. The coroner also ac­cepted the opin­ion of the psy­chi­a­trist who re­viewed the case, As­so­ciate Pro­fes­sor Michael Robert­son, that there “ap­pears to have been laud­able ef­forts to man­age the sit­u­a­tion in an im­per­fect set­ting”. This “im­per­fect set­ting” was not ex­am­ined by the coroner, who fo­cused on Wother­spoon’s death alone. But Dr Christo­pher Bench, the psy­chi­a­trist who worked in the Men­tal Health Unit, gave a sub­mis­sion to the in­quest about his view of the con­di­tions for men­tally ill in­mates in the unit.

Be­cause of the lim­ited num­ber of Cor­rec­tive Ser­vices Of­fi­cers avail­able to su­per­vise pa­tients housed in the Men­tal Health Unit, pa­tients were of­ten con­fined to their cells all day and had min­i­mal in­ter­ac­tion with other peo­ple. The cells in the Men­tal Health Unit had lit­tle light or fresh air … de­pri­va­tion, iso­la­tion,

lack of hu­man con­tact and lack of ex­ter­nal stim­u­la­tion can po­ten­tially in­crease symp­toms of acutely psy­chotic pa­tients.

In the months after Wother­spoon’s death, Bench and one of the men­tal-health nurses re­signed. Bench said he left be­cause he “be­lieved the con­di­tions in the Men­tal Health Unit were not suit­able for the prac­tice of good psy­chi­a­try”. The unit has since been closed down.

In March 2013, at the same time that David Wother­spoon was de­te­ri­o­rat­ing in­side his prison cell, an­other young Abo­rig­i­nal man was lan­guish­ing in cus­tody on the other side of the con­ti­nent. Jay­den Ben­nell was just 20 and, like Wother­spoon, had en­tered prison as a per­son clearly iden­ti­fied with chronic men­tal ill­ness. Ini­tially, he had reg­u­lar ses­sions with a psy­chi­a­trist, but then, largely due to a short­age of psy­chi­a­trists and a con­stant re-pri­ori­tis­ing of cases per­ceived as more se­ri­ous, he went seven months with­out an ap­point­ment, be­fore he hanged him­self in­side a stor­age room at Western Aus­tralia’s Ca­sua­r­ina Prison. Eight months later, also in Western Aus­tralia, Barry Stu­art, a 49-year-old prisoner, com­mit­ted sui­cide in Hakea Prison while wait­ing for a new pre­scrip­tion. Stu­art had a his­tory of de­pres­sion, drug-in­duced psy­chosis and at­tempts at self-harm, and had been tak­ing a pre­scribed an­tipsy­chotic med­i­ca­tion. How­ever, there was un­cer­tainty about whether this was the cor­rect med­i­ca­tion – he liked it be­cause it helped him sleep – and he needed a psy­chi­atric re­view to de­ter­mine if he should con­tinue. But the chronic short­age of psy­chi­a­trists meant he kept miss­ing out on his ap­point­ment. It was two weeks after he stopped tak­ing the med­i­ca­tion, be­cause his last script had run out, that Stu­art took his life. The in­quests into th­ese two deaths were held last year. Both heard sim­i­lar ev­i­dence about the paucity of psy­chi­atric ser­vices within the prison sys­tem – a con­sul­tant psy­chi­a­trist, Dr Adam Brett, de­scribed it as “un­der­funded and un­der re­sourced”. In an en­vi­ron­ment of scarcity, pris­on­ers with men­tal-health prob­lems per­ceived as less se­ri­ous, like Ben­nell and Stu­art, can sim­ply miss out. By the time of the in­quest into Ben­nell’s death, ac­cess to psy­chi­atric re­sources at Ca­sua­r­ina Prison had dou­bled from one to two days a week. When asked about the im­pact of this in­crease, Brett said they were still “just man­ag­ing the tip of the ice­berg”. He said that in the United King­dom ap­prox­i­mately 10 per cent of the men­tal-health bud­get is put into foren­sic men­tal health, whereas in Western Aus­tralia it’s more like 1 per cent. The coroner in­ves­ti­gat­ing th­ese deaths, Sarah Lin­ton, is­sued the same rec­om­men­da­tion for both: that the WA Depart­ment of Cor­rec­tive Ser­vices should in­vest sig­nif­i­cantly more re­sources in giv­ing pris­on­ers reg­u­lar ac­cess to psy­chi­a­trists, and adopt a more holis­tic ap­proach to men­tal-health care.

Coroners’ courts and the me­dia con­tinue to doc­u­ment cases of des­per­ately sick in­mates dy­ing in cus­tody. In De­cem­ber, Sen­a­tor Pat Dod­son, who was a com­mis­sioner on the Royal Com­mis­sion into Abo­rig­i­nal Deaths in Cus­tody, called on all state gov­ern­ments to leg­is­late a “duty of care” to pris­on­ers. This fol­lowed a re­port in Syd­ney’s Sun-Her­ald about the death in cus­tody in mid 2017 of an Abo­rig­i­nal man who, like Wother­spoon, spent his fi­nal days shack­led while brain dead. Eric Whit­taker, a fa­ther of five chil­dren, home­less and with drug abuse prob­lems, was ar­rested in Syd­ney last June for sev­eral of­fences, in­clud­ing al­legedly fail­ing to ap­pear be­fore court. NSW Cor­rec­tive Ser­vices com­mis­sioner Peter Sev­erin told The Sun-Her­ald that “bail was re­fused, most prob­a­bly be­cause of his in­abil­ity to have a place of res­i­dence”. On Fri­day, June 30, Whit­taker was trans­ferred to Parklea jail in Syd­ney’s north­west. “On ar­rival, he was au­to­mat­i­cally clas­si­fied as a max­i­mum-se­cu­rity in­mate be­cause Parklea does not con­duct se­cu­rity as­sess­ments on week­ends,” The SunHer­ald re­ported.

About 8am on Sun­day, July 2, cor­rec­tions of­fi­cers re­alised some­thing was wrong, they said. Doc­tors were later told Mr Whit­taker had been in an iso­la­tion cell, in­con­ti­nent, ag­i­tated and hand­cuffed, The Sun-Her­ald un­der­stands. “He had trashed his cell,” Mr Sev­erin said. “He was in­co­her­ent, he was quite un­con­trol­lable, so that’s when med­i­cal in­ter­ven­tion im­me­di­ately com­mences …” He was rushed in an am­bu­lance to Black­town Hos­pi­tal at 10.47am, bound hand and foot, un­der the su­per­vi­sion of two guards. Com­bat­ive on ar­rival, his con­di­tion then de­te­ri­o­rated fur­ther, The Sun-Her­ald un­der­stands.

It’s lit­tle won­der he was dis­tressed. Brain scans re­vealed that Whit­taker had had an aneurysm. He died in hos­pi­tal two days later. Whit­taker’s fam­ily re­leased a photo of him ly­ing in his hos­pi­tal bed, brain dead and shack­led at the an­kles. Whit­taker was re­port­edly the cousin of David Dun­gay Ju­nior, a 26-year-old who died in a state of great dis­tress while in­side the men­tal-health unit at Syd­ney’s Long Bay jail in 2015. Dun­gay was in the unit after be­ing di­ag­nosed with chronic schizophre­nia with acute psy­chosis. Ac­cord­ing to re­ports, he got into a con­fronta­tion with cor­rec­tive ser­vices staff be­cause he re­fused to fol­low an or­der to stop eat­ing bis­cuits. He was re­strained face­down on a mat­tress and in­jected with a tran­quil­liser, com­plain­ing he couldn’t breathe, shortly be­fore stop­ping breath­ing al­to­gether. He was due to be re­leased on pa­role in three weeks. In late Fe­bru­ary, an in­quest be­gan at the NSW State Coroner’s Court into the death in cus­tody of Ju­nior Fenika (To­gatuki). The 23-year-old, who’d de­vel­oped se­ri­ous men­tal ill­ness – in­clud­ing schizophre­nia – while in cus­tody, was be­ing held in an iso­la­tion cell in Goul­burn’s “su­per­max” prison. His sen­tence had fin­ished a month ear­lier and he was wait­ing to be de­ported to New Zealand (he’d left there at the age of four). Fenika’s men­tal health was re­port­edly de­te­ri­o­rat­ing when he took his life. His fam­ily is be­ing rep­re­sented by the Na­tional Jus­tice Project, a Syd­ney-based, hu­man rights– fo­cused law firm. Ac­cord­ing to their prin­ci­pal so­lic­i­tor, Ge­orge New­house, “Ju­nior was alone and des­per­ate and one night cut him­self with a ra­zor blade. But the fam­ily are look­ing for an­swers to some very tough ques­tions. How did he get the blade? Did his cries for help go unan­swered? And are our pris­ons filled with men­tally ill peo­ple who have ac­cess to shock­ingly lim­ited health ser­vices?”

Grow­ing num­bers of men­tally ill peo­ple en­ter­ing prison is a trend right across the Western world. The United States prison sys­tem now has the ig­no­min­ious dis­tinc­tion of be­ing the largest psy­chi­atric in­sti­tu­tion in the coun­try: more men­tally ill peo­ple end up in pris­ons than in hos­pi­tal beds. The roots of this prob­lem lie out­side the prison walls: a chronic lack of fund­ing of men­tal-health ser­vices in the com­mu­nity, a short­age of long-term men­tal-health beds, and a lack of ac­cess to sub­stance abuse treat­ments. Crim­i­nal jus­tice sys­tems that take the “tough on crime” ap­proach (pop­u­lar across many Aus­tralian ju­ris­dic­tions over the past decade) also help fun­nel the men­tally ill into prison, with this group of­ten end­ing up in jail for rel­a­tively mi­nor of­fences. “This is not about catch­ing the Mr Bigs of drug im­por­ta­tion or gun im­por­ta­tion,” says crim­i­nol­o­gist Pro­fes­sor Eileen Baldry. “This is largely about sum­mary of­fences, drug of­fences, mi­nor vi­o­lence, steal­ing, and the more we use the crim­i­nal jus­tice sys­tem to ad­dress those be­hav­iours then the more that group will end up in prison. And that’s what they have seen in the US and we are head­ing down that road, and we should not.” For Baldry, the im­por­tant ques­tion is not how we treat th­ese peo­ple in prison, but why we have them there in the first place. “The fun­da­men­tal point is that most of them should not be in prison. The fun­da­men­tal point is that if we strength­ened our com­mu­nity men­tal­health ser­vices, if we strength­ened our sup­port for

The United States prison sys­tem now has the ig­no­min­ious dis­tinc­tion of be­ing the largest psy­chi­atric in­sti­tu­tion in the coun­try.

dis­ad­van­taged and poor fam­i­lies, to sup­port their kids as well as them­selves when they are be­ing as­saulted by a range of things, in­clud­ing men­tal-health dis­or­der, they would not go to prison and they should not have to go to prison,” she says. Di­ver­sion­ary pro­grams that keep of­fend­ers with men­tal ill­ness out of prison have been in place for decades – and have been shown to re­duce the in­ci­dence of of­fend­ing. How­ever, across Aus­tralia their scale is rel­a­tively small. In New South Wales, the Jus­tice Health and Foren­sic Men­tal Health Net­work says it “strongly sup­ports the diver­sion of adults and young peo­ple with iden­ti­fied men­tal ill­ness from cus­tody”, and that be­tween 2016 and 2017 roughly 3000 adults and young peo­ple with men­tal ill­ness were di­verted to the com­mu­nity.

Last year at Cess­nock Cor­rec­tional Cen­tre, a steady stream of utes driven by men wear­ing high-vis en­tered through a back gate into an area piled with con­struc­tion ma­te­rial. In the dis­tance, heavy ma­chines cleared vast swathes of land – the site of a new “rapid-build” prison, one of two in New South Wales. In late Jan­uary, barely a year after con­struc­tion be­gan, the fa­cil­ity was of­fi­cially opened – ready for 400 in­mates to be housed in dor­mi­tory-style pods. The state is cur­rently spend­ing $3.8 bil­lion build­ing a dozen new prison fa­cil­i­ties, an ex­tra 7000 beds to cope with the rapidly ex­pand­ing prison pop­u­la­tion. In New South Wales, be­tween 2013 and 2016, the prison pop­u­la­tion grew by 26 per cent, but the fund­ing al­lo­ca­tion for the Jus­tice Health and Foren­sic Men­tal Health Net­work – which is ex­pected to de­liver ser­vices to the grow­ing num­ber of men­tally ill in­mates – hardly shifted. Jus­tice Health says it has dealt with this by de­vel­op­ing a new model of care: spe­cial­ist men­tal-health ser­vices are pri­ori­tised for the se­verely men­tally ill, while the less se­ri­ously ill are seen by a GP or nurse. It has also ex­panded the use of “tele­health” ser­vices and 24/7 hot­lines. How­ever, those who work in the sys­tem say se­ri­ous in­vest­ment is needed. “As a so­ci­ety we have in­vested much more in bricks and mor­tar of the pris­ons’ walls and the barbed wire and not enough in the hu­man re­sources in terms of psy­chi­atric care for this sec­tion of pris­on­ers,” says psy­chi­a­trist Dr An­drew El­lis, who works one day a week in­side a NSW prison. A re­cent re­port from the NSW In­spec­tor of Cus­to­dial Ser­vices found that the av­er­age wait time for an in­mate to see a psy­chi­a­trist is 42 days and to see a men­tal­health nurse is 27 days. “This has reached the limit of what is tol­er­a­ble,” El­lis says. He be­lieves the care pro­vided is “good enough” for some within the prison sys­tem, al­though not ideal by any means, and cer­tainly wouldn’t be equiv­a­lent to what they get in the com­mu­nity. Worse, how­ever, is that “there is a num­ber of peo­ple that we don’t even get to see”. In­creas­ingly, this leaves cor­rec­tive ser­vices of­fi­cers on the front­line of men­tal-health care. “So we be­come a nurse, we be­come a wel­fare of­fi­cer, we be­come a teacher, and in all hon­esty our train­ing is ex­tremely lim­ited to be able to deal with peo­ple with men­tal-health is­sues,” says Ni­cole Jess, a cor­rec­tive ser­vices of­fi­cer and chair of the prison of­fi­cers’ union. Jess works in­side Syd­ney’s Sil­ver­wa­ter Women’s Cor­rec­tional Cen­tre, where she says men­tally ill women fre­quently wait weeks for a spe­cial­ist bed. The beds ex­ist, but “just not enough, the de­mand is never met”. In the mean­time, the com­pro­mise is to place them in the prison’s in­duc­tion unit – the part of the prison for new ar­rivals. It’s the best of a bad choice: staff ra­tios are higher here, so there’s a lit­tle more care, but it’s a po­ten­tially volatile area. “This is where in­mates who first come into cus­tody go,” Jess ex­plains. “So you’ve got new peo­ple who’ve come in off the street, they’re with­draw­ing, they’ve been taken away from their kids, taken away from fam­ily, and they are not happy, and they have to share with men­tal-health in­mates.” Hous­ing se­verely men­tally ill in­mates in the main­stream prison pop­u­la­tion – even in an in­duc­tion area – makes them acutely vul­ner­a­ble. Prison is a sur­vival-ofthe-fittest en­vi­ron­ment. “[Other pris­on­ers] can as­sault them and they might com­plain to the guards, but the guards might think they are para­noid,” says El­lis. “Or they can have their med­i­ca­tion stolen … They’re of­ten wound up for en­ter­tain­ment by other pris­on­ers.”

Jess reg­u­larly deals with women in the main­stream prison pop­u­la­tion who are se­verely men­tally dis­tressed, from the acutely psy­chotic to the be­haviourally dis­turbed – women who can’t feed or bathe them­selves, or who are throw­ing fae­ces or blood. She does her best with what she has: “We some­times give them crayons, but then we’ve had in­mates who put the crayons in their eyes or they’ve eaten the crayon.” Of­ten her only tool is plac­ing them in seg­re­ga­tion. “We are lock­ing them in, on a reg­u­lar ba­sis,” Jess says. “For other peo­ple’s safety and their own safety.” She ac­knowl­edges that putting a prisoner in iso­la­tion can have an ad­verse ef­fect, but if the pri­or­ity is to get a prisoner to calm down, some­times “the only way you can do that is lock them down”. A re­cent in­ves­ti­ga­tion into Aus­tralian pris­ons by Hu­man Rights Watch found wide­spread ev­i­dence of peo­ple with men­tal ill­ness be­ing placed in pro­longed soli­tary con­fine­ment. Th­ese find­ings sup­port ear­lier work, from the Hu­man Rights Law Cen­tre, that says there is “sub­stan­tial” ev­i­dence across Aus­tralia that men­tally ill in­mates are of­ten “man­aged” by seg­re­ga­tion. This is de­spite a wealth of ev­i­dence go­ing back decades show­ing the dan­gers of this prac­tice. As El­lis points out, “for some­one who al­ready has dif­fi­culty ap­pre­ci­at­ing re­al­ity as part of their men­tal ill­ness – they might be hal­lu­ci­nat­ing, hear­ing peo­ple talk­ing, and it’s usu­ally un­pleas­ant con­tent – plac­ing them in soli­tary con­fine­ment tends to worsen their symp­toms and their out­comes”. Ac­cord­ing to a 2014 in­ves­ti­ga­tion into deaths in cus­tody by the Vic­to­rian Om­buds­man: “My in­ves­ti­ga­tion iden­ti­fied a num­ber of cases where pris­on­ers held in soli­tary con­fine­ment for up to 23 hours per day had at­tempted sui­cide or self-harm.” As a 30-year veteran of the prison sys­tem, Jess well un­der­stands the po­ten­tial harm of her ac­tions. “It just ex­ac­er­bates your stress lev­els, when you see that what you are try­ing to do could have an ad­verse ef­fect on them,” she says. Ac­cord­ing to Jess, it’s hard to es­cape a sense of fu­til­ity when “we are be­com­ing th­ese ware­houses and not ac­tu­ally treat­ing the per­son”. In­mates with men­tal ill­ness, par­tic­u­larly in com­bi­na­tion with sub­stance abuse, have high rates of re­cidi­vism. “A lot of the time it’s just a re­volv­ing door – they go out into the com­mu­nity, and there’s a lack of re­sources out in the com­mu­nity, and then they come back in … and it’s just not stop­ping, it’s get­ting worse.” From a psy­chi­atric view­point, in­car­cer­a­tion is fun­da­men­tally in­com­pat­i­ble with ef­fec­tive men­tal-health treat­ment. “You can’t give peo­ple ad­e­quate men­tal­health treat­ment in cus­tody, be­cause cus­tody is about de­ten­tion and pun­ish­ment, it is not about treat­ment and care,” says Dr Ness McVie, a foren­sic psy­chi­a­trist who has worked in both the Queens­land and NSW sys­tems. She says sim­ply be­ing placed un­der ob­ser­va­tion, most of it elec­tronic, in a cell on your own, with no ther­a­peu­tic in­ter­ven­tions but with ac­cess to il­licit drugs “is not men­tal-health treat­ment, it is just not … And most of th­ese guys in jail end up like David Wother­spoon, treated by men­tal-health ser­vices who are try­ing to do the best they can, but who don’t have many op­tions.”

There was a cu­ri­ous note in David Wother­spoon’s lengthy prison file. It con­cerned an in­ci­dent in late 2012, about six months be­fore he died, when he was mis­tak­enly told he was about to be paroled. What was in­ter­est­ing was Wother­spoon’s re­ac­tion: he was anx­ious about get­ting re­leased, and re­lieved when told the next day it was all a mis­take. I asked Co­rina Ma­son, his part­ner, about this, and she said it sounded about right. David liked in­sti­tu­tions, she told me; ju­ve­nile prison was where he dis­cov­ered his ap­ti­tude for art, and he al­ways turned to hos­pi­tal for help when he needed it. This prison sen­tence had come at a time when he was men­tally un­well, us­ing drugs again, about to lose the apart­ment he was liv­ing in, hav­ing prob­lems with his fam­ily. It might have seemed like a sav­ing grace. Even when his mind was tor­mented by ill­ness, it seems David al­ways knew enough to know when he needed help and care. His mis­take was to think this could be found in prison.

For sup­port, call Life­line 13 11 14.

David Wother­spoon. Im­age cour­tesy of the Wother­spoon fam­ily

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