OICS review of a death in custody at the AMC on 1st February 2022

In tragic circumstances, on 1st February 2022, a young man (Detainee A) in his 20's died in a cell of the Management Unit at the Alexander Maconochie Centre. The Management Unit at the time of the incident was being used as a COVID-19 isolation unit for all new receptions to the AMC. Detainee A had been admitted into custody at about 3:30pm on 31 January 2022, just 27 hours before his death.

Detainee A had identified a design flaw in the construction of the rear cell door which allowed him to slide a sheet under a horizontal rail and create a hanging point. Most regrettably, the review found that this risk had been identified and reported by AMC Facilities Management staff in 2015 but had not been addressed by the then AMC General Manager.

The review found that Detainee A was properly assessed by mental health professionals on his admission to AMC, who found no indicators that he was at risk of self-harm or experiencing suicidal ideations. It is also acknowledged that the attempted resuscitation of Detainee A was undertaken very well by custodial and nursing staff.

However, the review raises serious concerns about detainee safety, including concerns about the use of the restrictive environment in the Management Unit for COVID isolation as well as issues relating to prevention and management of self-harm incidents at the AMC that must be addressed by ACT Corrective Services as a matter of urgency.

The review makes five recommendations.

OICS acknowledges the trauma caused by this incident to the deceased’s parents and family, friends and loved ones, and extends
our sincere condolences to them.

* The deceased's family have requested that he not be referred to by his name.

Read the full report here.