Inquest finds 'shortfall in the care and supervision' as detainee knowingly held in 'unsafe' cell before death

CONTENT WARNING: This article refers to suicide and self-harm.

The ACT Government continued using cells it knew were “in one important aspect, unsafe” to house detainees, an inquest has found.

Luke Anthony Rich was 27 when he took his life while in custody at the Alexander Maconochie Centre (the AMC) on 1 February, 2022, one day after he was remanded in custody.

In his findings, Coroner Ken Archer found a “shortfall in the care and supervision of Luke contributed to his death”.

On 31 January, 2022, Mr Rich was arrested and taken into custody after allegedly assaulting someone. On his arrival at the AMC, Mr Rich’s physical and mental health was assessed.

During this process, Mr Rich said he had been recently using cocaine, but the nurse judged him to not be showing signs of drug and alcohol withdrawal. He also said he had been taking medication for insomnia for the past six months.

“Although a pattern of (perhaps considerably recent) cocaine use was identified, no plans were made to address withdrawal issues that might arise,” Coroner Archer found.

During a mental health assessment, Mr Rich denied any thoughts or plans of suicide or self-harm, and he was also given a ”Nil” rating on his suicide or self-harm.

Coroner Archer found that while the assessments of Mr Rich at the ACT Watch House were “adequate”, there were concerns with the care he received in custody.

Following these evaluations, Mr Rich was placed in a part of the AMC called the ”Management Unit”, which was being used for COVID-19 quarantine.

“That form of [COVID-19] isolation may have been justified on grounds of public health,” Coroner Archer found.

“However, that did not obviate the need to take reasonable steps to ensure the isolation was as safe as it reasonably could be.”

The rear doors of the Management Unit had what Coroner Archer termed “a ligature point”, which had been used by two detainees in suicide attempts in 2020.

Following those incidents, a brief to the Director-General of the ACT Government’s Justice and Community Safety Directorate called for the “urgent replacement” of the doors in the AMC’s Management and Crisis Support Units.

It would have cost $610,000 to replace the doors, according to Coroner Archer’s findings, but they were not replaced until after Mr Rich’s suicide.

Furthermore, a specific knife used to cut through materials was missing when Mr Rich’s body was discovered, though the inquest also heard more knives had since started to be provided to corrections staff.

Coroner Archer also found understaffing meant corrections staff were relying on CCTV to observe detainees.

“During that day, the observation regime was inadequate. In-person observations that were required were almost always not done,” he found.

Coroner Archer recommended the ACT Government give corrections staff guidance on how to observe detainees, that external consultants examine the safety of the rear doors (and that their results be published) and ACT Corrective Services develop a Suicide Prevention Framework.

Following the release of the findings, ACT Chief Minister Andrew Barr defended the decision to separate detainees for a quarantine period on Friday (23 August).

“During a pandemic, there were many, many other things that the government needed to do in order to ensure that there weren’t outbreaks in the jail,” he said.

“And that did mean utilising all of the available facilities to keep people separate, particularly those who were infected, particularly at a time when vaccination rollouts weren’t as universal as they are now.”

He said the ACT Government had already made several changes to its policies since Mr Rich’s death and would respond to the findings.

An inquest into the death of Justin James Cordy at the AMC on 26 February, 2023, is ongoing, and another male detainee died in custody in July 2024.

If you need help, or someone you know does, you can contact:

Lifeline’s 24-hour crisis support line – 13 11 14
Suicide Call Back Service – 1300 659 467
Kids Helpline – 1800 551 800 or Kids Helpline
MensLine Australia – 1300 789 978 or MensLine.

In a life-threatening emergency, call triple zero.