Deceased
Brent Reker
Demographics
35y, male
Coroner
Coroner Paul Lawrie
Date of death
2019-12-12
Finding date
2025-07-04
Cause of death
Hanging
AI-generated summary
Brent Reker, a 35-year-old prisoner with extensive history of suicide attempts (including hanging, overdose, and self-harm), died by hanging in Forbes Unit at Ravenhall Corrections Centre on 12 December 2019, approximately 90 minutes after transfer from Moroka therapeutic unit. Critical failures included: (1) his detailed suicide and self-harm (SASH) history was not discussed during the decision to transfer him, despite being documented; (2) his SASH risk rating of S4 and previous serious suicide attempts were not communicated to Forbes staff; (3) his Individual Management File did not accompany him to Forbes; (4) the planned pre-transfer discussion with the psychiatrist was abandoned; (5) delayed response to discovery of barricade prevented timely access to cell. The coroner found the failure to consider SASH history during discharge planning was a fundamental oversight that prevented properly informed risk assessment and planning.
AI-generated summary — refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
IN THE CORONERS COURT COR 2019 6794 OF VICTORIA AT MELBOURNE FINDING INTO DEATH FOLLOWING INQUEST Form 37 Rule 63(1) Section 67 of the Coroners Act 2008 Inquest into the Death of Brent Reker Delivered on: 4 July 2025 Delivered at: Southbank, Victoria Hearing Dates: 18, 19, 20 March 2024 Findings of: Coroner Paul Lawrie Representation: Mr L. Brown SC with Ms R. Singleton of Counsel instructed by Minter Ellison for the Secretary to the Department of Justice and Community Safety Ms R. Ellyard of Counsel instructed by Hall & Wilcox for GEO Group Australia Pty Ltd Mr M. McLay of Counsel instructed by Lander & Rogers for the Victorian Institute of Forensic Mental Health
Coroner’s Assistant: Leading Senior Constable F. Nation Keywords: Death in custody – suicide – prisoner transfer – suicide and self-harm (SASH) history – prominence of SASH information – response to cell barricade – cell cameras – remote viewing I, Coroner Paul Lawrie, having investigated the death of Brent Reker, and having held an inquest in relation to this death on 18 to 20 March 2024 – at Southbank, Victoria find that the identity of the deceased was Brent Reker, born on 18 September 1984 and the death occurred on 12 December 2019 at Ravenhall Corrections Centre (Forbes Unit), 97 Riding Boundary Road, Ravenhall, Victoria from: 1(a) HANGING I find, under section 67(1) (c) of the Coroners Act 2008 (the Act) that the death occurred in the following circumstances:
At approximately 3.30pm on 12 December 2019, Brent Reker was found unresponsive after hanging himself in the shower area of Cell 32 in the Forbes Unit at the Ravenhall Correctional Centre (RCC). He had used a ligature made from torn fabric. This was attached to a plastic chair wedged into the shower area of his cell as a hanging point.
Mr Reker had been in custody on remand for charges including aggravated home invasion and drug trafficking since 15 February 2019, when his bail was revoked.
Approximately 90 minutes earlier, Mr Reker had been transferred to the Forbes Unit from the Moroka Unit at the RCC.
SUMMARY Brent Reker’s background and recent incarceration
He is survived by his partner, Tess Spalding.
Mr Reker had an extensive criminal history across Victoria, Queensland and Western Australia. He was a member of an organised motorcycle gang, and his prior convictions included serious violence and drug offences.
On 12 September 2018, Mr Reker was arrested and charged with numerous serious offences including aggravated home invasion, conspiracy to commit aggravated home invasion and drug trafficking. He was remanded in custody at the Melbourne Assessment Prison (MAP).
During this first period of incarceration at the MAP, Mr Reker engaged in serious acts of suicidal or self-harming behaviour. On 1 November 2018, he was found hanging in his cell, having wedged a chair between two walls to create a hanging point. Custodial staff quickly intervened, and Mr Reker was transferred to St Vincent’s Hospital.1
On 2 November 2018, Mr Reker tied a smock around his neck to create a ligature. Once again custodial staff intervened, and Mr Reker handed over the ligature.2
On 10 November 2018, custodial staff discovered that Mr Reker had exposed a wire from an electric jug in his cell. He threatened to electrocute himself by placing the jug in the cell toilet and touching the water.3
On 18 January 2019, Mr Reker was released on bail to appear at the Melbourne Magistrates’ Court on 6 March 2019.
1 Exhibit 24 – CB260 2 Exhibit 24 – AM1.19 3 Exhibit 24 – AM1.19
Moroka Unit – Ravenhall Correctional Centre
The unit is not designed to treat acute mental illness.
By 11 December 2019, Forensicare staff had concerns that Mr Reker was having an adverse influence on the other prisoners in the unit. Specifically, that he was destabilising the prisoner group and undermining therapeutic engagement.
At approximately 7.40am on 12 December 2019, Mr Reker was found in a cell with another prisoner. When he was asked to leave the cell by a correctional officer he replied with challenging language, although he did leave as asked.
At 9.15am and 10.02am, Mr Reker tried to telephone his partner, Tess Spalding, but on both occasions the call went unanswered.
At approximately 12.35 pm, Mr Reker approached a Forensicare nurse who was on his way to see another prisoner. Mr Reker was said to have adopted an intimidating demeanour and said, ‘You’re a fucking joke’. At about the same time, another prisoner ingested metal swarf4 and the Moroka Unit was locked down as a result.
4 Chips, turnings, filings or shavings produced by machine tools such as drills.
At approximately 1.15pm, custodial and clinical staff at the Moroka Unit held a case conference to discuss Mr Reker and the difficulties he presented for the operation of the unit. The incidents involving Mr Reker that morning were considered to be indicative of his threatening behaviour towards staff. A plan was made to transfer Mr Reker from the Moroka Unit, but to have a consultant psychiatrist speak with him first.
The case conference finished at 2.00pm and staff attempted to contact the consultant psychiatrist, Dr David Thomas, but were unable to do so as Dr Thomas was briefly offsite in a meeting. By this stage the unit had been locked down for an extended period and custodial staff wished to transfer Mr Reker to the Forbes Unit while the other prisoners remained locked down. A decision was taken to conduct the transfer without Mr Reker first speaking with the psychiatrist.
Transfer to Forbes Unit
The Forbes Unit is a management unit for prisoners who are required to be separated from the remainder of the prison population for management or other reasons. It can accommodate 42 prisoners and has two observation cells.
At 2.26pm, custodial staff arrived at Mr Reker’s cell to begin his transfer to Forbes.
When Mr Reker was asked to place his hands through the trap5 in the cell door to be handcuffed, he first swallowed some metal swarf. He did not hide what he was doing.
Following this, he was transferred to Forbes without further incident.
At 2.34pm, Mr Reker arrived at Forbes and was inducted into the unit. He denied any thoughts of suicide or self-harm and was placed in Cell 32, which is a regular cell and not an observation cell. He was placed on hourly observations.
At 3.28pm, two custodial officers went to Mr Reker’s cell door to tell him that the consultant psychiatrist had come to the unit to speak with him. They received no reply and opened the viewing pane6 to the cell only to find it covered with toilet paper. A short 5 The ‘trap’ is a small ‘letterbox’ like opening in the cell door at about waist height. Described by CO McEvoy at Exhibit 14 – CB058 6 The viewing pane is a window in the cell door, situated higher than the ‘trap’, with a hinged metal shutter on the outside which may be opened or closed by custodial officers.
time later Dr Thomas arrived at the cell door and recalled that he could hear grunting from inside.
They arrived at the rear of the cell at 3.36pm and observed a chair wedged above the shower in the cell but they could not see Mr Reker. They ran back inside the main building and to Mr Reker’s cell door to inform other custodial officers and the custodial supervisor.
At 3.37pm, a custodial officer opened the trap door on the cell door and used a walking stick to push out of the way a mattress which Mr Reker had put up against the inside of the door. Custodial officers could then see Mr Reker laying unconscious inside the shower with a ligature around his neck and a ‘Code Black’ was called.
At 3.39pm, the cell door was opened and custodial officers entered, together with Dr Thomas. They found Mr Reker was unresponsive and began cardiopulmonary resuscitation (CPR).
At 3.43pm, clinical staff arrived in response to the Code Black call and Mr Reker was pulled out of the cell into the corridor where emergency treatment could be delivered more effectively. Resuscitation attempts continued without success and Mr Reker was eventually declared deceased by paramedics at the scene at 4.07pm.
(a) Correctional Officers and supervisors of the RCC Moroka and Forbes Units;
(b) Forensicare clinical staff;
(c) RCC senior management;
(d) Ambulance Victoria paramedics and Victoria Police members responding on 12 December 2019;
(e) Victoria Police investigators; and
(f) Victorian Institute of Forensic Medicine (VIFM) forensic pathologist and toxicologist.
(a) CCTV recordings from the Forbes Unit on 12 December 2019;
(b) Scene photographs;
(c) Prisoner records and incident reports;
(d) GEO and Forensicare correspondence;
(e) Minutes of Moroka Unit meetings for 11 and 12 December 2019;
(f) Justice Health records;
(g) Justice Health report – April 2021;
(h) Justice Assurance and Review Office (JARO) report – 19 August 2021; and
(i) Forensicare Clinical Risk Assessment and Management Policy. 7
I took over carriage of this investigation in October 2022 and, after a directions hearing on 23 March 2023, the scope of the inquest was set as follows:
Removal of Brent Reker from Moroka on 12 December 2019, including:
(a) Brent Reker’s history of placement within Ravenhall Correctional Centre
(b) SASH history & Risk Management Plan;
(c) events leading to the decision to remove Brent Reker from Moroka;
(d) case conferences on 11 and 12 December 2019;
(e) plan for transfer (including risk assessments and use of risk assessment tools);
(f) circumstances of the transfer as implemented.
7 This is not intended as an exhaustive index to the coronial brief or additional materials.
On 26 February 2024 I was afforded a guided view of the RCC Forbes Unit and other areas of the facility. This was also attended by the legal representatives for the interested parties.
The inquest was conducted over three days from 18 to 20 March 2024 and the following witnesses were called:
(a) Kate McMahon – Correctional Manager RCC8;
(b) Malcolm Garth – Correctional Supervisor RCC Moroka Unit;
(c) Rory McEvoy – Correctional Officer RCC Forbes Unit;
(d) Domenic Olsen – Correctional Officer RCC Forbes Unit;
(e) Timothy Tranter – Correctional Officer RCC;
(f) Dr David Thomas – Forensicare, RCC Lead Consultant Clinical Operations; and
(g) Colin Caskie – General Manager RCC
On 13 December 2019, Dr Melanie Archer, Forensic Pathologist at the Victorian Institute of Forensic Medicine, conducted an external examination of Mr Reker’s body (including CT scan), and produced a report dated 23 December 2019.9
The examination revealed a broad ligature mark (3 to 3.5 cm wide) over the front of the neck, passing under the jaw and over the larynx. Scattered petechial haemorrhages were 8 Roles and positions are as at December 2019.
9 Exhibit 24 – CB035
seen around the eyes. The eyes also showed subconjunctival congestion. Also observed was angulation of the thyroid greater cornua and the left greater horn of the hyoid bone, with no clear fracture. These observations were in keeping with the known circumstances of the hanging.
Also noted were subtle left anterior rib buckle fractures and an abrasion over the sternum in keeping with the cardiopulmonary resuscitation.10
Toxicological analysis of postmortem samples showed the presence of methadone, mirtazapine, olanzapine and chlorpromazine. The presence of these drugs and their concentrations were unremarkable.11
Dr Archer provided an opinion that the cause of death is ‘1(a) HANGING’. I accept Dr Archer’s opinion.
BRENT REKER AT THE MOROKA UNIT Purpose and operation of the Moroka Unit
Dr David Thomas, a specialist Forensic Psychiatrist and lead consultant for Forensicare’s clinical operations at RCC12, explained the basis upon which a prisoner13 may be placed in Moroka and that entry to the unit is voluntary. The basis for placement is where a prisoner has been assessed as demonstrating repetitive and entrenched complex and challenging behaviour that places him at significant risk of self-harming, interpersonal violence, or other serious harmful behaviour.14
Dr Thomas further explained: The main Moroka program is an intensive Dialectical Behaviour Therapy (DBT) program of 12 weeks’ duration, broken into three modules. Participants learn to
10 CB039 11 CB041 12 Positions and roles are described as at the time of the events in question.
13 From the clinician’s perspective, prisoners within units operated by Forensicare are referred to, and regarded as ‘patients’. However, the term ‘prisoner’ is used throughout these findings for the sake of consistency.
14 Exhibit 20 – CB242
use appropriate, adaptive coping skills rather than resorting to challenging behaviour to address situations. DBT is primarily conducted via a mix of group and individual sessions, and consequently, a person’s ability to navigate the dynamics of their group and to make and maintain group connections is critical to their success in the program. To facilitate group connection and continuity, there is a discharge and intake cycle every four weeks. While the program is intended to run for 12 weeks, there is inherent flexibility and a person could be in Moroka for a shorter or longer period depending on the circumstances and their needs.15
Mr Reker’s arrival at Moroka Unit
On 22 November 2019, Mr Reker was admitted to Moroka upon his transfer from PPP to RCC. His arrival was shortly before the scheduled start of the next Dialectical Behaviour Therapy module and so his expected stay at the unit was to be slightly longer than the standard 12 week period. Dr Thomas had general oversight of each prisoner’s clinical care whilst they were on the unit16 and he was supported by Moroka’s psychiatry registrar, Dr Dayla Metter. Dr Thomas considered that Mr Reker appeared reasonably settled in his first two weeks at Moroka and was not mentally unwell.
On 25 November 2019, Dr Metter reviewed Mr Reker and noted, inter alia, that he had been diagnosed with post-traumatic stress disorder, emotional dysregulation, and antisocial personality traits in the context of complex trauma. Whilst in prison, Mr Reker had reported chronic low mood, high levels of anxiety and repeated flashbacks to past trauma relating to his stepfather. It was also noted that these symptoms were at their worst when he was locked down. He also reported multiple suicide attempts throughout his life by various methods including hanging, overdose, running in front of traffic, and driving into a tree. After this, Mr Reker had daily reviews with psychiatric nurses.17
On 28 November 2019, Dr Metter again reviewed Mr Reker with a focus on adjusting his medication.
15 Exhibit 20 – CB245 16 Dr Thomas was on leave until 26 November 2019 and so was not present for Mr Reker’s induction or his first four days on the Unit.
17 Exhibit 24 – CB232
On 4 December 2019, Mr Reker attended a multi-disciplinary clinical review. He complained about the unit being ‘too quiet and boring’ but nevertheless appeared reasonably well motivated. There was no evidence of psychosis or affective disorder, and he was assessed as mentally stable. He admitted to having suicidal ideation but denied having any intent.18
On 10 December 2019, Mr Reker was again reviewed by Dr Metter concerning his medication and he reported being tired of the ‘group dynamics’ within Moroka. Dr Metter’s impression was that Mr Reker was genuine in seeking help and was motivated to engage appropriately in the program. However, during the review Mr Reker said words to the effect, ‘Just between you and me, everyone is planning on self-harming on Sunday’19 – that is, 15 December 2019. Dr Metter understood that this was intended to be an act of rebellion against the unit.
Dr Thomas was on leave at this time and so Dr Metter sought the advice of Dr Pang, Consultant Psychiatrist, who was covering Dr Thomas’ position. Dr Metter discussed her concerns about the threatened action with Stephen Blucher (GEO Correctional Manager) and Kate McMahon (GEO Correctional Manager – Forensic Mental Health) and then sent a wider email to arrange a meeting for 1.00pm on 11 December 2019.20 The correspondence read, in part: … (there is a heightened sense of frustration at the moment on the unit, a peer meeting was called today for the prisoner’s [sic] to vent their concerns – and allegedly most of them mentioned they feel self harm is the only way to get their needs met and appear focused on this) I would like to inform the team in a structured and calm manner to avoid any heightened emotions, and come up with a unified approach and plan from our multidisciplinary team as well as our colleagues on GEO.
I discussed with Steve Blucher and Kate McMahon today with thanks, and they would like a decision to be made ASAP before the weekend, and have suggested 18 Exhibit 20 – CB247-248 19 Exhibit 24 – CB234 20 Exhibit 4 – CB317
exiting a member in order to contain the situation. I have spoken to my interim supervisor Sam Pang who suggested we hold on this decision until the meeting tomorrow. …
I note that Dr Metter used the term ‘influential prisoner’ in this email as an unstated reference to Mr Reker.
Throughout the day Mr Reker was seeking PRN21 medication and appeared to be doing so for himself as well as for other prisoners.22 11 December 2019 – GEO & Forensicare meeting
In advance of the meeting, at 11.05am Kate McMahon sent an email to her GEO colleagues including senior management which read, in part: Forensicare have advised they believe REKER to be the influencer/organiser here and they have come to a consensus that REKER should be the one removed from Moroka. …23
The email also included a request for an intelligence briefing concerning Mr Reker.24 However, it appears that the intelligence briefing was not meaningfully carried out. Ms McMahon gave evidence that personnel from the Intelligence Department did attend the meeting, but they didn’t have the correct information to hand because they thought the discussion would concern a different prisoner.25 It appears that this mistake was never remedied.
The meeting took place and involved the GEO senior management team, Forensicare staff and GEO Moroka staff. Detailed minutes were taken.26 Dr Metter provided the background to the situation. Although there appears to have been differing views concerning the proposed response to the situation, it seems to have been generally agreed 21 pro re nata – as needed 22 Exhibit 13 – CB311 23 Exhibit 4 – CB319 24 Exhibit 4 – CB319 25 T015; Exhibit 2 – CB178 26 Exhibit 3 – CB327
that Mr Reker was adversely influencing the other prisoners on the unit. Kate McMahon stated in evidence: … there was a lot of angst I recall around – just around the feeling that Forensicare had for – with Mr Reker at the time. His demeanour was not like that of the other prisoners.
He’s a much – was a much bigger man in stature as well, and the rest of the unit prisoners, they seem to sort of really look up to him and I recall that being a big issue at the time from the Forensicare team, being concerned that he was leading the rest of the guys elsewhere.27
EVENTS AT MOROKA UNIT ON 12 DECEMBER 2019 Chronology of events at Moroka
12:35pm~ Mr Reker engages in an intimidating verbal exchange with a Forensicare nurse.
12:35pm Mr Reker reports to custodial staff that another prisoner in Moroka has metal swarf and intends to ingest it.
12:39pm Moroka Unit is locked down.
1:15pm~ GEO and Forensicare meeting concerning Mr Reker commences.
2:00pm~ GEO and Forensicare meeting concludes.
2:00pm Separation Order signed – authorising Mr Reker’s transfer to Forbes.
27 T025 28 Times followed by the symbol ~ are approximate.
2:00pm~ Dr Thomas and Dr Metter travel offsite to have a discussion concerning recent events.
2:26pm Custodial staff arrive at Mr Reker’s cell to initiate his transfer to Forbes.
2:28pm Mr Reker ingests metal swarf before leaving his cell.
Events prior to the meeting
At approximately 7:40am a custodial officer walked past a cell in Moroka to see Mr Reker in there with another prisoner. It was not Mr Reker’s cell, and it appears that the issue of prisoners being in cells that were not their own was a frequent problem.29 When Mr Reker was told to get out of the cell he replied, ‘Fucking hell someone’s feeling like a tough [expletive deleted] today’.
At approximately 12:35, a male Forensicare nurse was going to see another prisoner when Mr Reker walked towards him in a threatening manner and said, ‘Are you here to see me?’ When the nurse replied in the negative, Mr Reker said in an aggressive tone, ‘You’re a fucking joke’. This prompted the nurse to reach for his duress alarm, but instead he left the unit without activating it.30
At 12:35, Mr Reker approached the GEO officers’ post in Moroka and reported that another prisoner had picked up metal shavings (swarf) and was going to swallow them.
The swarf had apparently been left by a contractor drilling a metal telephone cabinet during minor maintenance. The custodial officer approached the other prisoner who then consumed the swarf on a piece of bread and said that the pieces he had consumed were about 4 cm long.
GEO & Forensicare meeting
A second meeting involving members of the GEO senior management team, Forensicare staff and GEO Moroka staff was held between 1.15pm and 2.00pm.33
Dr Thomas gave evidence regarding the concerns surrounding Mr Reker’s continued placement at Moroka, stating: … [my] sense at the time was that this was not sustainable, and it wasn’t safe and if not handled appropriately, then this would result in a further dislocation of Mr Reker from the rest of the program. So it was perhaps the best decision would’ve been to exit him temporarily from the program.34
Dr Thomas disagreed that there was a consensus among nursing staff that the sooner Mr Reker was moved out of Moroka, the better it would be for the remainder of those on the program. However, there were some members of the nursing team that were clearly uncomfortable with his presence.35
I am satisfied that the decision to transfer Mr Reker from Moroka was ultimately a decision for GEO, supported by advice provided by Forensicare. It is not surprising that there may have been differences of opinion among Forensicare staff concerning the viability of Mr Reker continuing at Moroka, but the ultimate clinical advice appears to have been that the risk of disruption to the other prisoners at Moroka was too great.
I do not consider that it is useful or appropriate to examine the foundations for the ultimate clinical advice. The relevant matter is that this is the position that was reached and which informed GEO management, who had to decide whether to move Mr Reker, and where to move him to. I accept that Forensicare does not make decisions concerning the movement and placement of prisoners, although these decisions are informed by the clinical recommendations of Forensicare’s staff.36 33 Exhibit 3 – CB330. The start time of the meeting is not recorded in the minutes but is included in the JARO Review at AM1.17.
34 T230 35 T230 36 Exhibit 20 – CB241; T275
Kate McMahon gave evidence that Mr Reker’s suicide or self-harm (SASH) history was not discussed at the meeting37, and I accept this to be so.
It does not appear that the shortcomings in the intelligence briefing that had been arranged for 11 December 2019, were overcome for the meeting the following day. The deficit in the information is reflected in Mr Garth’s evidence that Mr Reker’s previous suicide attempts or ideations were never brought up in any of the conversations he had with Forensicare.38
The JARO report noted that Mr Reker’s SASH history and issues with separation were not recorded in the minutes of this meeting.39 The JARO report also properly captured the significance of this when it concluded: The apparent failure to discuss Mr Reker’s SASH history raises two distinct concerns, Firstly, had this information been considered, the decision to transfer Mr Reker from a therapeutic unit directly to a management unit may have been scrutinised further. Secondly, failing this information meant that a well-planned and coordinated discharge of Mr Reker, potentially involving a review of his S risk rating, increased observations in his new unit or consideration of the materials that he was allowed to access in his new cell, did not occur.40
The failure to consider Mr Reker’s SASH history, including the context of previous episodes, in either of the meetings on 11 and 12 December 2019 amounts to a fundamental oversight. Consequently, it was not possible for the planning for his discharge from Moroka, or his placement at the new unit, to have been fully informed.
A Separation Order was signed by Malcolm Garth at 2:00pm on 12 December 2019 and authorised separation of Mr Reker in the Forbes Unit for 7 days. Under the heading ‘Description of situation leading to this separation’ the order states:
37 T026 38 T059 39 Exhibit 24 – AM1.25; Exhibit 3 – CB330 40 Exhibit 24 – AM1.25
Permission to separate Brent REKER due to threatening behaviour towards staff and ongoing concerns about his influence in the Moroka Unit. PIM #338542 41 The plan for transfer to Forbes
… DECISION WAS MADE TO EXTRACT REKER FROM THE UNIT TO MANAGEMENT [Forbes] PENDING A PLACEMENT DECISION. EXTRACTION TEAM
Dr Thomas explained that the purpose of his planned discussion with Mr Reker was to give him a clear reason why he was being transferred from Moroka, to work with him to maintain his commitment to treatment goals and provide positive feedback, and to talk to him about what he needed to do to possibly return to Moroka.44 Dr Thomas was emphatic about the need for this discussion and the potential clinical benefits.
Dr Metter recalled in her written statement that: … Dr Thomas made it clear during the meeting that he wanted to speak with Mr Reker before the move, and he would like to be there at the time of the move. This was agreed to by GEO … … We had concern that Mr Reker would be angered by the decision to move him …45 41 Exhibit 12 – CB 337. The Incident Report #338542 is Exhibit 8 – AM4.1 42 Exhibit 7 – CB168 43 Exhibit 8 – AM4.1
44 T232 45 Exhibit 24 – CB235
TRANSFER TO FORBES Deviation from the plan
Shortly after the conclusion of the meeting at 2:00pm, Dr Thomas and Dr Metter travelled a short distance off-site to have a discussion concerning Mr Reker and the recent events.
Dr Thomas did not receive any telephone calls while he was offsite, and he had no recollection of any missed calls. He was highly critical of the timing of the transfer and disagreed that Mr Reker needed to be moved from Moroka immediately and stated in evidence: We re-convened 24 hours later, nothing happened. There was no urgency to move him. I cannot understand why he was moved within an hour, There wasn’t any, nothing else had happened, you know, so to my mind, the nature of the move had been determined and I see no grounds, and I still can’t see with reflection and hindsight, I still cannot understand what the justification was for moving him prior to that assessment, and to my mind that’s the real issue here …46
It is unclear who made the decision to transfer Mr Reker before Dr Thomas had an opportunity to speak with him. Malcolm Garth did not know who made the decision to initiate the transfer. He recalled that he was under the direction of Kate McMahon, but he did not nominate her as the source of the decision.47 Mr Caskie gave evidence that the ultimate responsibility for decisions about where a prisoner will be placed in RCC rests with the Sentence Management Division of Corrections Victoria48, and I accept this to be the case. However, this does not answer the question concerning the decision about precisely when to initiate the transfer. It is likely that the decision concerning the timing of the move came from GEO management.
The submissions on behalf of Forensicare argue, in short, that no reason had been discovered, other than a perceived efficiency or expediency, to transfer Mr Reker before Dr Thomas had spoken to him.49 In contrast, the submissions on behalf of GEO assert that the timing of the transfer was driven by pressure from Forensicare staff and, had there been a request to wait for Dr Thomas to return, Kate McMahon said they would have waited.50 In fact, Ms McMahon was not as clear as this, saying she would have ‘called that back up the line’ and ‘probably would have pushed it to wait for Dr Thomas, `cause that was the initial plan’.51
It is not necessary or useful to embark on what is likely to be a barren forensic excursion to determine precisely from whom, and to what extent, there was pressure to depart from the original plan. What is revealed is that Dr Thomas considered the original plan, marked by a conversation between him and Mr Reker prior to transfer, was of very high clinical importance and I accept Dr Thomas’ evidence in this regard. I also accept that there are operational complexities for GEO staff who have to implement the transfer, and it was advantageous to conduct the exercise while Moroka was in lock down. However, the failure of custodial staff and clinical staff to be ‘on the same page’ about the timing of the transfer and whether it was necessary to deviate from the original plan demonstrates an alarming breakdown in communications at this juncture.
Ingestion of swarf
BR53 Why’s that?
49 Forensicare submissions – paragraphs 12 to 14 50 GEO submissions – paragraphs 19 to 21
51 T048 52 Custodial Supervisor 53 Brent Reker
CS As I said, the psych’s going to have a chat with you and explain all the reasons.
BR So, I’m getting kicked out of this unit?
CS At the moment, yes.
BR Why, because I had one argument with the … CS … is going to come down and have a chat with you in a little while BR So where’s Forbes, is it the slot?
This prompted a further exchange as follows: CS (addressing other custodial staff) He’s just taken some pills.
(addressing BR) What is it?
BR It’s steel.
CS (addressing other custodial staff) So he’s just eaten the steel filings that he took this morning . The steel filings he took out of the phone this morning, he’s just drinking them down.
As the exchange was taking place, Mr Reker put some of the metal swarf into a cup and mixed it with protein powder54 as a drink, before consuming it. From what can be seen on the BWC recording of Mr Reker’s handling of the swarf, it appears to be very fine material. Moreover, he did not appear to have any difficulty swallowing it. The impression is that the material was comprised of very small metal filings or chips rather than long tendrils or shards.
Dr Thomas also gave evidence which casts light on the true nature of the material: 54 T075
… in Mr Reker’s case, I did not consider his ingestion of the metal shavings … to indicate an increase in self-harm.
It was really part of a group protest. He wasn’t the only one that ingested the metal filings … I requested to see what these filings were because it was very unusual for us to have anything like that on the unit and I was shown [these] filings which were produced by some works done earlier on in the day and the filings were really miniscule and so I wasn’t particularly concerned.55
Dr Thomas’ evidence makes clear that he was aware, or believed, that Mr Reker had ingested some swarf earlier in the day, together with some other prisoners. It is in this context that he asked to have a look at it and formed a view that it was unlikely to present any risk to physical health. He did not feel there was a need to get the general health service involved.56
The first impression of the custodial supervisor’s reaction to Mr Reker ingesting the swarf in his cell at 2:28pm, shown on the BWC recording, is that it is strikingly ‘matter of fact’. I am however satisfied that the composition of the material was likely of the same character as the material that had been inspected by Dr Thomas earlier.
Furthermore, although not stated explicitly, the very strong implication that may be drawn from Dr Thomas’ evidence is that, after he inspected the material, he told GEO staff that he thought it would not pose a risk to physical health. Given this very likely background, the ‘matter of fact’ response by the custodial supervisor may be seen in its proper context.
These meetings are held daily to review each prisoner with a SASH rating above ‘S4’ (that is ‘S1’ to ‘S3’).57 The levels of the SASH ratings are described as follows: S1 – Immediate risk of suicide or self-harm 55 T204 (verbal hesitations omitted). See also T233.
S2 – Significant risk of suicide or self-harm S3 – Potential risk of suicide or self-harm S4 – Previous history of risk of suicide or self-harm58
At the time of the transfer, Mr Reker’s SASH rating was ‘S4’, the lowest rating available for a prisoner that has had an incident in the past but for whom there are no current concerns.59
In addition to his SASH risk, Mr Reker had the following ratings for other risks:
(a) Placement – rated as ‘T3’ from 8 November 2018, meaning that he ‘presents as vulnerable in a custodial environment’;
(b) Psychiatric – rated as ‘P2’ from 25 September 2019, meaning that he had a ‘significant ongoing psychiatric condition requiring regular monitored psychiatric treatment’; and
(c) Medical – rated as ‘M2’ from 14 September 2018, meaning that he had a ‘medical condition requiring regular or ongoing treatment’.60
Mr Garth explained the structure of the Individual Management File (IMF) that arrives with each prisoner and is used as part of the reception assessment. The IMF is in two parts: the first part (sections 1, 2 and 3) relates to the prisoner’s current incarceration; the second part (section 4) relates to historical incarcerations and, according to Mr Garth, is referred to only rarely.61
the revocation of his bail after the first period on remand, and the closeness in time of the two periods of incarceration. In reality, the ‘historical’ 2018 information was recent information which was highly relevant to Mr Reker’s current incarceration.
Moreover, the episode may be long past. At the other end of the spectrum of examples is Mr Reker’s case. He had multiple serious episodes of attempted suicide only 14 months earlier. Without at least some detail of the prisoner’s SASH history, the ‘S4’ rating is of very limited value.
These facts lead inexorably to a conclusion that the structure of the IMF, and the evident practice to refer only rarely to the ‘historical’ Part 2 of the IMF, invited a situation where RCC custodial staff were apparently unaware of critical SASH information for the entire time Mr Reker was in their custody. This gap in information is also evident in the extensive note in the GEO Gateway records63 pertaining to the induction case management meeting on 28 November 2019 which does not include any meaningful detail of previous SASH incidents.64 Given the character of the notes for this meeting, and the absence of any meaningful SASH information within them, I conclude that the details of Mr Reker’s SASH history was not discussed at that time. Accordingly, while the details may have been known to Forensicare staff and contained in Mr Reker’s clinical records, GEO staff remained unaware despite recent incidents being described in custodial records (including the IMF file) that were available to them.
RECEPTION & MONITORING IN FORBES UNIT 62 T086 to 087 63 The GEO system for ‘Local Plan File Notes – Ravenhall’: Exhibit 13 – CB305 to 312 64 Exhibit 13 – CB307
The Prisoner Observation Form for Forbes records that Mr Reker was received into the unit at 2.45pm and placed into Cell 32. He was to be observed every hour.65 Rory McEvoy, GEO Correctional Officer at the Forbes Unit, gave evidence that he did the induction for Mr Reker, and the process usually takes 3 to 5 minutes.66 Information accompanying Mr Reker
CO McEvoy recalled that he had no early notification that Mr Reker was coming into Forbes, but he thought he was told by a supervisor that a new prisoner was coming in.
There was very little information transmitted to staff at Forbes when Mr Reker was transferred, and critical information was absent. CO McEvoy stated that Mr Reker’s IMF did not come with him67, and I accept this to be the case. Kate McMahon conceded that the IMF should have been taken over to Forbes together with Mr Reker.68
I consider that this was a significant error in the transfer process with a telling consequence. CO McEvoy, who performed the induction in Forbes, stated that he did not believe that Mr Reker had a SASH risk rating and there was no immediate SASH history.69
CO McEvoy did not know that Mr Reker had just recently ingested metal filings or swarf.
He explained that he considered this to be an act of self-harm and, had he have known of it, he would have raised a ‘Moroka 1’ call which would have prompted the attendance of a nurse from Moroka to assess Mr Reker.70
Although hypothetical reruns of alternate facts are rarely useful, in this instance I consider it likely that if CO McEvoy had known of the swarf incident and initiated a call, Forensicare staff at Moroka would have likely conveyed the conclusion reached by Dr Thomas. Namely, that the ingestion of the swarf presented no real risk to physical health and was an act of protest rather than genuine self-harm.
CO McEvoy was given only a quick ‘rundown’ from a custodial supervisor before Mr Reker was received into the unit. He recalled being told that Mr Reker ‘was a risk to our 65 Exhibit 15 – CB339
safety and had been threatening towards other prisoners’, and this was the reason for the transfer.71
Induction and cell allocation at Forbes Unit
The Forbes Unit has the capacity to accommodate 42 prisoners and has two observation cells.73 The JARO Review includes a full schematic of Forbes with the cell numbers. Mr Caskie explained in evidence that Cells 41 and 42 are the two observation cells, and Cells 18 to 27 have internal CCTV cameras. Accordingly, 12 of the 42 cells have internal CCTV cameras.74 CO McEvoy explained that the two safe cells were only for prisoners that were brought in on an ‘S1’ or ‘S2’ rating.75
CO McEvoy gave further evidence regarding the induction process, explaining that it includes informing the prisoner of the rules of the unit, and questions of the prisoner concerning any medications they may be prescribed, and a last set of questions concerning suicide or self-harm.
The induction form for Mr Reker was not found and did not form part of the coronial brief. Instead, a blank induction form was produced to show the structure of the document.76 It is a one-page document which is clearly not designed to record or guide a proper assessment of a prisoner’s SASH risk, or other risks.
71 T113 72 T031 73 Exhibit 24 – AM1.14. ‘Observation cells’ were also called ‘safe cells’ by various witnesses, also called ‘Muirhead cells’ (T271) after the Chair of the Royal Commission into Aboriginal Deaths in Custody.
74 T270-271; Exhibit 23; Exhibit 24 – AM1.15
75 T114 76 Exhibit 16 – CB173
Mr Caskie produced a document comprising the Forbes cell count for 12 December 201977 and I am satisfied that there were no available ‘safe cells’ or ‘camera cells’ into which Mr Reker could have been placed instead of Cell 32.
CO McEvoy explained that once Mr Reker was in his cell he would be on hourly observations because he had just been received into the unit.78 Although CO McEvoy did not know of Mr Reker’s SASH risk rating, he explained that a rating of ‘S3’ requires hourly observations of the prisoner.79 Accordingly, the initial observation regime applied to a newly received prisoner is equivalent to the regime for a prisoner with a ‘S3’ rating.
CO McEvoy also stated that once he had placed a prisoner in their allocated cell, he would then go to either the PIMS or the Gateway system to check information, including any SASH rating.80
Another GEO Correctional Officer at Forbes, CO Olsen, explained that a prisoner arriving at Forbes would generally be accompanied by a Separation Order and the Forbes staff would be made aware of a reason why a prisoner was coming to the unit. Further, if a prisoner has a SASH rating, that would generally be communicated by a telephone call or in a document accompanying the prisoner.81
I am satisfied that the absence of the information that should have accompanied Mr Reker, which included his SASH rating, did not impact his cell allocation or the observation schedule that was initially applied to him. Nonetheless, this outcome was the result of mere happenstance rather than the product of an informed decision at the time of induction.
77 Exhibit 23; T271
78 T117 79 T117; 129 80 T117 81 T141-142 82 Times followed by the symbol ~ are approximate.
2.45pm Mr Reker is placed in Cell 32 and his hourly observation schedule commences.83 3:25pm~ Dr Thomas and Dr Metter arrive at Forbes.84 3:28pm CO Tranter and CO McEvoy go to the door of Mr Reker’s cell to tell him that the consultant psychiatrist has come to speak with him.
3:28:41pm Dr Thomas arrives at Cell 32 (and makes a gesture indicating a person performing ‘push ups’).
3:29:35pm Dr Thomas leaves and walks to the supervisor’s station.
3:30pm~ CO Olsen and CO McEvoy go outside and make their way to the ‘run out’ area at the rear of the cell to look inside from this vantage point.
3:33:18pm CS Carly Smith arrives at Cell 32.
3:34:46pm CO Tranter arrives at Cell 32 carrying a walking stick.
3:36:58pm CO Olsen and CO McEvoy run back into the corridor and inform their colleagues that there was a chair wedged between the shower screen and the cell wall. CO Olsen assumed that Mr Reker may have tried to hang himself.
3:37:45pm Dr Thomas very briefly looks through the trap into Cell 32.
3:38:18pm Dr Thomas looks though the trap a second time.
3:39:00pm Cell door opened.
Discovery of Mr Reker’s hanging
83 Exhibit 15 – CB 339 84 Exhibit 20 – CB253 85 Exhibit 17
CO Tranter called out to Mr Reker and said that people were there to see him but there was no reply. CO Tranter stated: I recall hearing noises like shuffling and little bangs, general movement, which I thought were coming from inside the cell.86
When Dr Thomas looked through the open trap in the cell door a short time later, he could not see inside because Mr Reker had placed a mattress up against the cell door and used paper to obscure the adjacent viewing panel. Dr Thomas recalled: I could hear rhythmic grunting of the type you would expect would be associated with vigorous exercise such as push ups … I considered it probable at the time that he was angry and doing push-ups to avoid engaging ...87
Dr Thomas’ communicated his supposition about the push ups to the custodial officers that were with him, and he can be seen on the CCTV recording making a gesture consistent with this. At 3:29:35pm, Dr Thomas walked back to the supervisor’s station to see if he could observe the inside of the cell via CCTV. He was informed that there was no camera inside the cell but there was CCTV coverage of the ‘run out’ area at the rear of the cell.
At about this time, CO McEvoy and CO Olsen went outside the main building to get to the ‘run out’ area at the rear of Cell 32. From there, it was hoped to be able to get a proper view into the cell through a rear window. When they arrived, CO Olsen could see a chair wedged in the shower area, but he could not see Mr Reker. He assumed that Mr Reker may have tried to hang himself88 and told CO McEvoy what he had been able to observe. They both ran back inside the unit.
On 26 February 2024, during a view of the Forbes Unit, I was walked through the route taken by CO McEvoy and CO Olsen from the ‘run out’ area to re-enter the main building and to the front of Cell 32. It was apparent that, even at a run, the journey would take several minutes as there are multiple locked doors and gates. CO McEvoy explained that some of these doors include timed interlocks that prevent opening until an earlier door is locked. Also, that various gates must be manually unlocked. Moving quickly, CO 86 Exhibit 19 – CB172 87 Exhibit 20 – CB254 88 Exhibit 18 – CB054
McEvoy estimated that it would take two and a half to three minutes (one way).89 I am satisfied that CO Olsen and CO McEvoy moved as quickly as was reasonable to return to the front of Cell 32 and update their colleagues.
CO Tranter recalled hearing a radio transmission that was distorted and ‘sounded like someone was running’.90 I am satisfied this was either CO McEvoy or CO Olsen trying to communicate with their colleagues inside the main building.
While CO Olsen and CO McEvoy were outside the building there was continuing activity at the front of Cell 32. At 3:33:18pm, CS Carly Smith attended at the cell and appears to speak with her colleagues. There is no apparent urgency in the actions of CS Smith or the custodial officers at the cell door prior to the return of CO Olsen and CO McEvoy.
At 3:34:46pm, CO Tranter returned to the front of the cell with a walking stick to push the mattress away from the inside of the door.
At 3:36:38pm, CO Olsen and CO McEvoy ran back into the corridor leading to Cell 32.
At 3:37:45pm, Dr Thomas very briefly looked through the trap in the cell door. He repeated this with a longer look 33 seconds later at 3:38:18.
Opening of the cell door
The cell door was opened at 3:39:00pm. That is, approximately 10 minutes after discovery of the barricade and more than 2 minutes after CO Olsen and CO McEvoy reported what they had seen from the ‘run out’ area. The time taken to get into the cell is of concern, and an evident lack of urgency was conceded by Mr Caskie.91
CO McEvoy stated that the Custodial Supervisor (Carly Smith) would have to obtain authority from the shift manager before Mr Reker’s cell door could be opened. This approval is sought and given via radio.92 Similarly, CO Tranter explained that, if there 89 T134-145. Also CO Olsen at T144.
90 Exhibit 19 – CB172
was no response from a prisoner inside a cell, correct procedure was not to open a cell until given clearance to do so by a supervisor.93
Mr Caskie explained the training given to custodial officers for situations where they cannot see or communicate with a prisoner inside a cell: … one of the things that we train them to do in responding to incidents is two things, determine and assess. What that means is before you rush into a situation, determine the facts, take the time if you have it to understand what you’re dealing with and then once you understand that, then conduct the appropriate assessment …94
I accept the need for great caution before a cell is opened in circumstances where custodial officers cannot see or communicate with the prisoner inside. Indeed, CO McEvoy spoke about the dangers of a prisoner feigning unconsciousness, or ‘playing possum’.95 Nonetheless, the time taken to assess the situation in Mr Reker’s cell and then to gain entry was too long. With a more urgent initial response to the discovery of the barricade, and with more prompt action in response to the news delivered by CO McEvoy and CO Olsen, it is entirely plausible that valuable time (at least in the order of one to two minutes) could have been saved.
It is not possible to conclude that, if resuscitation efforts had been commenced earlier by these few minutes, these efforts would have led to a different outcome. Nonetheless, the desirability of commencing CPR as soon as possible remains obvious, and the course of events reveals a missed opportunity to commence resuscitation efforts earlier by some minutes.
In August 2021, RCC conducted ‘Operation Augmenting’96 focussing on the response to a death in custody incident. This was followed by ‘Operation Sightless’ in September 2023, which was an exercise designed to test response capacity to various emergency scenarios, including where a prisoner could not be seen inside a cell.97
93 T172 94 T286 95 T133 96 Exhibit 22 – CB146 97 Exhibit 22; T269-270
Remote monitoring of the interior of cells and seeing past barricades
Mr Caskie explained the requirement to balance the need for cameras in cells to monitor prisoners who may be at higher risk, against the need to provide a suitable environment for prisoners who may be in the unit long term. This is understandable, but Mr Caskie also agreed that it would be possible to have cameras in all cells, including for prisoners where a camera was not required for constant monitoring, and then have the capacity to activate any camera should a situation require it.98 As previously detailed, the Forbes Unit has cameras in only 12 of its 42 cells, and Mr Caskie gave evidence that, to his knowledge, there was no plan to increase the number of cameras.99
Mr Reker had created a barricade in his cell, with the mattress rested up against the inside of the cell door preventing the ability to observe through the trap. If his cell had been fitted with an internal camera, it would have been a simple matter to activate it to see what was going on inside. This is not to say that an internal camera will always provide an effective means to observe a barricaded prisoner.
I am mindful of the reality that prisoners can resort to various means to obscure cameras in cells and it may be very difficult to prevent such actions. Relevantly, Mr Caskie explained the possibility of using other devices to see inside a barricaded cell. Mr Caskie stated that a ‘snake camera’ or borescope had been used successfully in incidences and in training exercises.100 Technology of this sort has advanced considerably in recent years and become less expensive. A suitable borescope, available in each prison unit, would provide a valuable additional tool to observe inside a barricaded cell. There is nothing before me to suggest that the cost of acquisition or training would make such an initiative impractical.
Hanging point and ligature
Once inside the cell it was CO McEvoy who removed the ligature.101 The hanging point and ligature were not subsequently photographed and, in any event, the scene had been substantially disrupted by the extensive resuscitation efforts. Nonetheless, the chair and ligature should have been photographed, no matter where they had ended up.
CO Olsen described a plastic chair that had been wedged sideways in the shower area at about the height of the shower head. He recalled that the ligature was made of a green material, either a towel or a ripped up sheet.102
Dr Thomas’ evidence on this subject appears to be a combination of reconstruction and recollection. He stated: I reflected later that Mr Reker must have wedged the chair between the shower head and the wall of the shower, ripped a bedsheet and attached the bedsheet to the chair. The chair itself was the ligature point.103
During the view of the scene on 26 February 2024, the type of chair was shown. It was a simple lightweight polypropylene stackable chair. A demonstration was also conducted showing how the chair could be wedged sideways in the shower area.
I am satisfied that the hanging point was created by Mr Reker when he wedged a plastic chair sideways in the shower area. It is more likely that the ligature he made was from a bedsheet rather than a towel.
CO Olsen explained that all the cells in Forbes, apart from the safe cells, had a chair of the same type.104 In response to this risk, the JARO Review noted that Corrections Victoria issued a directive to all prisons that chairs should be removed from the cells of all prisoners who had a SASH risk rating of S3 or higher, unless it had been determined at a High Risk Assessment Team meeting that a chair should remain.105 I consider this to
101 T128 102 Exhibit 18 – CB055; T145-145; 155 103 Exhibit 20 – CB255
104 T158 105 Exhibit 24 – AM1.35
be a substantial response to reduce the risk that a chair may be used in cell to create a hanging point.
The Separation Reform Project is a project to review Corrections Victoria’s management of prisoners who are subject to separation regimes and are accommodated in high security, management and intermediate regime units. Although ‘separation’ of a prisoner is not defined in Victorian legislation, it was accepted that Mr Reker’s transfer to Forbes (a management unit) constituted a separation and the Separation Reform Project remained part of the scope of the inquest. However, the material ultimately available in the coronial brief explained the project in a complete way and the matters touched upon were uncontentious.106
Jennifer Hosking, Assistant Commissioner (AC), Sentence Management Division – Corrections Victoria, provided a written statement107 explaining the background, objectives and implementation of the Separation Reform Project.
AC Hosking explained that separation is used as a last resort, and prisoners should be managed under the least restrictive conditions required to manage safely any identified risks. The aim of the Separation Reform Project is to improve the system for management of separated prisoners by making it less isolated and more trauma-informed to reduce negative impacts. The means to achieve this include providing prisoners subject to separation with the opportunity to address the reasons for separation and the opportunity to progress towards accommodation in the mainstream prison population.
(a) separation is no more restrictive than is necessary to manage the risks warranting the use of separation;
(b) separation is not authorised where alternate (and less restrictive) behaviour management methods are appropriate;
106 T012 107 Exhibit 24 – CB256.1
(c) separation is not used as a punitive measure; and
(d) when a decision is being made whether to separate a prisoner, their mental illness and/or disability is considered where these factors may have contributed to the prisoner’s negative behaviour.
An important part of the project is the implementation of the Separation Assessment Form (June 2021) which prompts the decision making process to adhere to these aims.
I also note the implementation of a new ‘separation’ warning flag in PIMS (July 2022) which will allow corrections and medical staff to see a prisoner’s separation history and also allow Corrections Victoria to better understand the frequency and use of separation across the prison system.
Finally, the ‘Men’s system reform’108 is intended to provide a new operating model for male prisoners subject to separation, or where separation is being considered. The new model includes an emphasis on alternatives to separation and an individualised approach in line with therapeutic and rehabilitative processes.
The new operating model is expected to be implemented across the men’s prison system through 2025 and 2026. I am satisfied that it represents a thoughtful culmination of the work done in the Separation Reform Project.
I thank the Coronial Investigator and those assisting for their work in the investigation.
I thank the Coroner’s Assistant and all Counsel and instructors for their assistance during the inquest.
108 The Separation Reform Project also includes ‘Women’s system reform’ which is noted but not otherwise canvassed in the context of this inquest: see Exhibit 24 – CB256.6
RECOMMENDATIONS I make the following recommendation(s) connected with the death under section 72(2) of the Act: Recommendation 1 That, in order to promote an increased awareness by custodial managers and custodial officers of the essential details of previous episodes of suicidal or self-harming behaviour by a prisoner, and to prominently convey meaningful context associated with a SASH rating, the Secretary to the Department of Justice and Community Safety:
(a) review the manner in which the details of previous episodes of suicidal or selfharming behaviour are contained in a prisoner’s Individual Management File and other prisoner information systems intended for use by custodial officers, with the aim of making this information more prominent in an operational setting; and
(b) require prison operators to review the training provided to custodial supervisors and custodial officers to reinforce the need for a thorough examination of prisoner information relating to any SASH rating, in order to properly inform prisoner assessment processes and relevant operational decisions concerning the prisoner.
Recommendation 2 That, in order to promote an increased awareness by custodial managers and custodial officers of the essential details of previous episodes of suicidal or self-harming behaviour by a prisoner, and to prominently convey meaningful context associated with a SASH rating, GEO Group Australia Pty Ltd:
(a) review the manner in which the details of previous episodes of suicidal or selfharming behaviour are contained in GEO prisoner information systems with the aim of making this information more prominent in an operational setting; and
(b) review its training of custodial supervisors and custodial officers to reinforce the need for a thorough examination of prisoner information relating to any SASH rating, in order to properly inform prisoner assessment processes and relevant operational decisions concerning the prisoner.
Recommendation 3 That, in order to permit remote viewing of the interior of a cell in the event a prisoner blocks direct physical means of seeing inside the cell, the Secretary to the Department of Justice and Community Safety require prison operators to install a video camera (or cameras) in every management unit cell.
Recommendation 4 That the Secretary to the Department of Justice and Community Safety require prison operators to:
(a) have available in all units in prisons, a borescope camera (or similar technology) for use by custodial officers as an alternate or emergency means of seeing inside a barricaded cell; and
(b) adequately train custodial officers in the use of the borescope camera (or whatever similar technology may be adopted).
DIRECTIONS Pursuant to section 73(1) of the Act, I direct that this finding be published on the Coroners Court website in accordance with the Rules.
I direct that a copy of this finding be provided to the following: Tess Spalding – Senior Next of Kin James Reker and Lynette Kersten Department of Justice and Community Safety Correct Care Australasia Pty Ltd GEO Group Australia Pty Ltd Department of Health Victoria Victorian Institute of Forensic Mental Health Senior Constable Jason Christian – Coronial Investigator Signature: ______________________________________ Coroner Paul Lawrie Date: 04 July 2025 NOTE: Under section 83 of the Coroners Act 2008 ('the Act'), a person with sufficient interest in an investigation may appeal to the Trial Division of the Supreme Court against the findings of a coroner in respect of a death after an inquest. An appeal must be made within 6 months after the day on which the determination is made, unless the Supreme Court grants leave to appeal out of time under section 86 of the Act.
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