Risdon Prison Hospital & Forensic Mental Health Services

OMBUDSMAN TASMANIA REPORT ON AN INQUIRY INTO RISDON PRISON Risdon Prison Hospital & Forensic Mental Health Services Volume 1 June 2001 1 Office of the Ombudsman Telephone: Toll free 1800 001 170 (03) 6233 6217 Facsimile: (03) 6233 8966 Email: [email protected] Internet: http://www.justice.tas.gov.au/ombudsman The Office of the Ombudsman is located at Ground Floor, 99 Bathurst Street, Hobart, Tasmania, 7001. © Office of the Ombudsman, Tasmania 2001 This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without written permission. ISBN 0-7246-8008-X (Set) ISBN 0-7246-8006-3 (Volume 1) 2 FOREWORD The investigation into the Risdon Prison Hospital and the Risdon Prison Complex represents probably the most major investigations ever undertaken by a Tasmanian Ombudsman. I believe that the reports speak for themselves in respect of the independence of the investigative process, the depth of analysis and the comprehensiveness of the background research undertaken. The investigation was initiated as an own motion inquiry by the then Ombudsman following discussions with the Minister for Justice, Hon Dr Peter Patmore, in response to a number of tragic inmate deaths and a series of adverse incidents, including escapes and riot situations. Managing a prison is no easy task. Prisons are like no other institutions and prisoners form a highly volatile, vulnerable and atypical society. Prison authorities at Risdon and elsewhere bear a degree of responsibility that goes well beyond what is required of most authorities, public or private, in meeting this duty of care. In addition to a duty of care to prison employees and to the community at large, which expects to be protected from criminals, there is a special duty of care owed to a group of people who are deprived of many personal liberties by virtue of incarceration and who have special physical, mental, emotional and social needs, which frequently differ from those of society as a whole. The rules which govern such a complex structure must strike the right balance between security and containment on the one hand and rehabilitation and restitution of inmates’ self esteem on the other, and that balance is not easily attained. A number of the problems uncovered in the investigation, particularly in the Prison Hospital, stemmed from an imbalance in which security concerns were given greater weight than prisoner rehabilitation. The most glaring example of this was that the medical staff in the Prison Hospital reported to the Department of Health and Human Services, but the nursing staff reported to the Department of Justice and Industrial Relations. This anomalous situation, which was identified in a Coroner’s report as well as ours , has now been rectified and nursing staff are to be transferred to the Department of Health and Human Services. No prison is a pleasant place, but the Risdon Prison is a particularly unpleasant place. It is bleak, cold and grey and, even if a very large amount of money were to be spent on the facility, it is unlikely that it could ever conform to contemporary prison standards. The buildings reflect years of relative neglect by successive governments and even when it was built, forty years ago, the Prison would have been out of date and totally inappropriate in its design for the rigours of a Tasmanian winter. Moreover, it was built as a Maximum Security Prison and remains so, even though the demand has never been for a full maximum security facility. When additional stresses, such as an unexpected surge in prisoner numbers or a significant change in the nature of the prisoner population occur, as has happened at Risdon, there is an inevitable strain on resources and management. Staff morale drops, inmate unrest and dissatisfaction escalate and the system begins to crack. This is what had happened at Risdon, and had been happening for a significant period of time prior to the investigation. The period of active investigation took place between September 1999 and May 2000. Because the Coroner was conducting a separate inquiry into the deaths in custody, it was agreed not to release the Ombudsman reports until the Coroner had released her report, which she did on 26 March 2001. There is a high degree of consistency between the two independent reports. Another factor which influenced timing of the release of the Ombudsman reports has been the rapid developments that have occurred since active investigation ceased in May 2000. Since that time both Departments have taken action to remedy and improve many aspects of the administration and management of the Risdon Prison, Risdon Prison Hospital and “special institution”. The most major of these is the Government’s decision to build a new prison on the Risdon site, which is due for completion in 2008, and to build a separate, secure mental health facility for those who have a mental disorder and are detained under a restriction order. While the main focus of the reports is on the situation as it was at the time of active investigation, in fairness to the two Departments and because the public should know what is happening in terms of prison reform, whenever possible changes that have occurred since May 2000 have also been incorporated. While this could be seen as 3 diluting the unalloyed impact of the investigation findings, I am frankly more interested in ensuring that strategies for improvement are put in place rather than in simply finding fault for past events. Irrespective of the dreadful events which may have precipitated them, the present Government is to be commended on the many initiatives it has taken in relation to prison reform, particularly the decision to build a new prison. It is a matter for great regret that these much needed reforms come too late for five young men. Framing the recommendations was a difficult task, as these too were overtaken by the developments in prison reform. A number of the recommendations included in early drafts of the reports have already been implemented, and are now redundant. Some recommendations will become redundant once the new prison is built, but many cannot wait that long. Consequently, they have been recommended for urgent implementation, even though it might well be argued that to do so would be a waste of resources. In our view, it is not. One such example relates to the installation of sensor devices on the existing perimeter fence. This is seen as essential to enhance security at the Prison, even though it is a relatively short term measure. Another is to continue to upgrade facilities to remove suspension points and to take other actions to better address the risk of suicide and self harm. The primary objective has been to make recommendations that are realistic in a resource sense, but still meet the needs identified in the investigations. There has been considerable discussion with the two Departments to establish the feasibility of some recommendations and, as at the date of publication, many of the recommendations have already been accepted in principle. Others are still under consideration or are in dispute and will be the subject of further negotiation once the Government has had an opportunity to consider them. There is one further point I wish to make. The investigation has been substantially funded from the Ombudsman’s existing budget allocation and has required two senior staff to be taken off line for a significant time. Even the most superficial comparison with the cost of other, comparable Commissions of Inquiry will indicate the strain that this has placed on my staff resources. Undertaking major inquiries of this nature is an important function of the Ombudsman’s Office and is consistent with the Ombudsman’s statutory obligations, but in future there must be due recognition of the cost. Finally, I wish to acknowledge the many people who have worked on the two reports. Robyn Hopcroft, David Fleming and Tony Priest have been the three main investigators. Ms Hopcroft has been responsible for writing the Prison Hospital report and David Fleming and Tony Priest prepared the report on the Risdon Prison Complex. Valuable assistance has been provided by my executive assistant, Karen Adams, and of course Damon Thomas, who initiated and oversighted the investigation until his resignation as Ombudsman in October 2000. Janine O’Grady Ombudsman (Acting) 21 June 2001 4 Table of Contents 1. INTRODUCTION................................................................................................................... 7 2. THE INVESTIGATION....................................................................................................... 10 3. THE LEGISLATIVE FRAMEWORK AND THE DUTY OF CARE................................ 13 3.1 INTERNATIONAL LAW ......................................................................................................... 13 3.2 NATIONAL GUIDELINES ...................................................................................................... 13 3.3 STATE LEGISLATION............................................................................................................ 14 3.4 THE COMMON LAW DUTY OF CARE ...................................................................................... 15 3.5 THE ISSUES......................................................................................................................... 16 3.6 PERFORMANCE MEASURES.................................................................................................

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