Questions raised after five mentally-ill prisoners die in Australia

By Dragan Stankovich
21 August 2001

The Australian Broadcasting Corporation Four Corners current affairs program earlier this year provided a rare and disturbing glimpse into the conditions inside the country’s prisons. Titled No Safe Place, the story examined the death of five mentally-ill prisoners within just four months at Tasmania’s Risdon jail, which combines a maximum security penitentiary with a hospital for violent prisoners who suffer acute mental illnesses.

The five inmates died in late 1999, just months after Tasmania’s Labor Party government rejected any review of the prison following a riot by 100 prisoners. Risdon is Tasmania’s main jail, built in 1960, based on a stark open-air design from the American South. Simon Copper, a lawyer interviewed by Four Corners, described Risdon as “cages with yards” with “concrete steel floors washed away by repeated scrubbing so they are down to the stone”. He concluded: “Just the whole environment was an appalling one... Just nothing about it is conducive to proper housing of people, and, I suppose, rehabilitation.”

From the details unearthed by Four Corners, the five dead men were in prison because they were unable to obtain the psychiatric treatment they needed. Moreover, once inside Risdon, they were not only denied proper assessment and treatment, but were also placed in life-threatening environments.

At least two of the men were previously homeless, living on the streets of Hobart—Chris Douglas, 18, and Fabian Long, 21. Douglas was the first to die. Considered borderline intellectually disabled, he committed suicide after being sexually assaulted. He had been placed in a protection yard with paedophiles and sex offenders. A coroner’s report noted that he was slightly built.

The day Douglas killed himself, he had asked to see a psychiatrist but none were available. When a guard discovered him hanging in his cell, it took five minutes to obtain a key to the cell door. Douglas may have died during that time.

That morning, Douglas had phoned his mother Vickie to tell her that he had already tried to kill himself once that day. He “tied his television cord around his neck and woke up on the floor shaking,” Vickie Douglas told Four Corners. Asked why she hadn’t reported this to prison officials, she replied: “Trying to tell the prison officials about anything is just hopeless.”

The next to die was Thomas Holmes, 29, who suffered from paranoid schizophrenia and had been in and out of hospitals. He was arrested after burning down a hotel. His family did not apply for bail because they thought that he would be given the help he needed inside Risdon. The jail’s clinical director, Dr Alan Jager, had examined Thomas and made notes of his delusional tendencies but did not mention the possibility of suicide.

A nurse had put Holmes on suicide watch but in the lowest category. The hospital staff had no idea of his previous history. He hanged himself with his shoelaces after he had been in prison for less than a week. A previous coroner’s report had warned about hanging points in cells and revealed that warders were not trained to deal with suicidal prisoners. But authorities took no action.

Carol Rue, a friend of Holmes, commented: “Here’s a person who’s schizophrenic, who’s burnt a pub because he believes aliens are entering Earth through it, a highly delusional person who’s there for psychiatric assessment, who’s been diagnosed as a schizophrenic, who is left in a cell for two days with his shoelaces. I don’t know whether anyone talked to him or made sure he was OK because no one has written any notes anywhere.

“We didn’t know how big a failure that special institution was going to end up being. We would’ve been better off bringing him here and padlocking him in my bedroom and making sure he took his drugs.”

Jack Newman, 57, was also found hanging in his cell. A former government scientist, he had been found insane by a jury in 1983 after he brutally murdered his wife. Detained indefinitely, there were clear signs that he became suicidal after losing all hope of release. The coroner criticised Dr Jager’s handling of Newman as “not adequate”, noting that he ignored a senior psychiatrist’s diagnosis that Newman suffered a major depressive disorder.

Laurence Santos, 20, died suddenly in his prison bed after receiving high drug dosages. The young man had developed schizophrenia after a bike accident, which he blamed on aliens. His parents had asked the police to take him to hospital for psychiatric assessment and care. His illness was diagnosed and he was released a month later when his condition stabilised.

Santos stopped taking his medication, however, and went into the bush for 10 days without food or shelter, suffering delusions that his parents were trying to kill him and his dog. When he returned, he murdered his father with a butcher’s knife and attempted to kill his mother. He was also detained indefinitely after being found not guilty on grounds of insanity.

In Risdon, he was given Clozapine, a drug that can have fatal side effects if given in high dosages and without close monitoring. Despite the known dangers of convulsions, the treatment began at 100mg a day and went rapidly to 900mg a day, the maximum recommended dosage. The coroner could not determine the precise reason for his death but pointed to the possibility of suffocation from sleeping face down or heart failure, both of which could be caused by the high dosage of Clozapine. “There was inadequate monitoring of the effects of the drug on Laurence Santos, in particular, the dangerously high blood Clozapine levels,” she said.

Fabian Long was found dead with a piece of torn sheet around his neck. The precise cause of death was uncertain but he had been sexually abused. Diagnosed as suffering severe schizophrenia, with hallucinations, he had been jailed after stabbing several people in the street. In Risdon, he was re-diagnosed as suffering from a personality disorder and placed in the general prison population.

“Look at the system”

No Safe Place tended to focus on the jail’s clinical director, Dr Jager. He had been the only applicant for the post when it was advertised following Chris Douglas’ death. Jager had trained under Professor Paul Mullen, his referee, who is a leading authority in forensic psychiatry, but he had not fully qualified as a psychiatrist.

Dr Jager had only 15 months’ clinical experience, all of which was supervised. The job specifications required eight years’ experience, including treatment of chronic mental illnesses that can sometimes cause violent behaviour. Inadequately trained for the position, Dr Jager treated Laurence Santos in a way that the coroner considered dangerous.

In the case of Fabian Long, the coroner criticised Dr Jager for placing him in the general prison population, ignoring the diagnoses of four other psychiatrists, and being aware of the risks of sexual assault and suicide. The coroner recommended that the clinical director’s position be reviewed.

The five men who died had mental illnesses that required specialist care and decent facilities. As Professor Mullen told Four Corners: “I think it’s very easy to point a finger at one vulnerable doctor, and assume all of the difficulties that occur are due to him, when, it seems to me, you have got to look at the system.” Mullen described forensic psychiatry services in Tasmania as “unacceptable”.

There is just one secured medical facility able to handle people with mental illness who present a risk to themselves or others—a closed ward at Hobart’s Royal Derwent Hospital. Specialist units have been shut down, leaving only three major hospitals providing services for the mentally ill, and some small services at Royal Derwent.

Over the past 15 years, both Labor and Liberal governments in Tasmania have savagely cut spending to social services—perhaps more than in any other Australian state. Mental health services were among those targetted. Throughout the 1980s and 1990s, the number of psychiatric beds was cut by 30 percent, without any adequate community facilities to replace them. Hundreds of mental health services staff lost their jobs. One result is that many mentally ill people have become homeless.

Once incarcerated, the treatment given to mentally-ill prisoners is in line with deliberately brutal conditions for all prisoners. After the 1999 Risdon riot, Tasmanian Attorney General Peter Patmore was asked why money was not spent to improve jail conditions. “I feel no sympathy for the prisoners of Risdon,” he replied.

The government has boasted of cutting costs in the jails. Tasmania’s prison population has doubled in recent years, but the Justice Department website declares that despite the increase, “cost efficiency has been substantially improved, staff numbers reduced and costs contained”.

The barbaric conditions inside Risdon only came to light because five men died in such a short time, giving rise to coroner’s reports and, eventually, to national television coverage on Four Corners. Since the publicity over the Risdon deaths, the government has moved Dr Jager to the University of Tasmania until his contract runs out.

It will not close Risdon prison, however. Instead, it has promised to spend $53 million over six years to develop the jail and provide a separate mental health facility. Even if this promise is kept, spending $9 million a year will do little to improve the prison’s conditions, and the underlying lack of mental health services in the community will remain.