CONTENT WARNING: This article refers to suicide and self-harm.
Recommended scheduled checks on a detainee were not carried out because prison staff were on their lunch breaks, an inquest has heard.
Family gathered in person at the ACT Coroners Court and watched remotely as a coronial inquest into the death of Justin James Cordy at the Alexander Maconochie Centre (the AMC) began this week.
He died by suicide on 26 February 2023, the day after he was refused bail for various offences and taken into custody at the AMC.
In her opening address, Coroner Lucinda Wilson said the inquest would examine the “quality of care, treatment and supervision” Cordy received in the days before his death.
She said the inquest will also hopefully offer answers to his family.
“We are here to find the truth and make recommendations which will hopefully make tragedies like this less likely,” she said.
Counsel assisting the coroner Vanessa Thomas told the court Cordy had been in and out of jail since 2017 and had used illicit drugs in the past, including GHB and crystal methamphetamine (also known as ice).
He had also made a suicide attempt during a previous period in jail in 2020.
After being released from custody at the AMC on 21 February, the court heard Cordy went to a house in Tuggeranong where he allegedly assaulted someone and damaged their property.
Police were informed of the alleged acts, and they found Cordy in a Theodore car park.
The court heard he allegedly rammed the police car, rendering it undrivable, before leaving the scene on foot.
Ms Thomas said Cordy was allegedly “seen brandishing a large kitchen knife” in Chisholm as he reportedly tried to steal a car.
Cordy was ultimately arrested while threatening self-harm. He was taken to hospital but discharged shortly afterwards.
Cordy faced the ACT Magistrates Court on 25 February. He was remanded in custody and another court date was scheduled for March 2023.
On arrival at the AMC, Cordy’s physical and mental health were assessed, with a mental health nurse determining there should be hourly checks on him and recommending a follow-up appointment.
Ms Thomas said he denied having any “thoughts, attempts or plans” of suicide.
The court heard the last check on Cordy, seen on CCTV footage, was at 11:40 am on 26 February.
Ms Thomas said it was policy at the time detainees were locked in their cells while staff took their lunch hour from 12 pm to 1 pm.
CCTV footage indicated no further checks were done until 1:03 pm when Cordy was discovered unconscious in his cell.
A code pink was called (for a medical emergency) and resuscitation efforts began; however, Cordy could not be revived.
At the start of the inquest, Cordy’s ex-wife, Sheryl Cordy, teared up as she spoke of the impact Cordy’s death had on his family.
“Justin had a great sense of humour and he lit up the room every time he came into it,” she said.
“Justin was an amazing father. He loved his kids and they loved him.”
Ms Cordy said she wished he was still alive to see his children grow and reach milestones in their lives, such as seeing them graduate, learn to drive and meet any grandchildren.
“I guess I’ll never be the same – something will always be missing from our lives,” she said.
The inquest is expected to continue for two weeks.
If you, or someone you know, needs help, contact:
Lifeline’s 24-hour crisis support line – 13 11 14
Suicide Call Back Service – 1300 659 467
Kids Helpline – 1800 551 800 or kidshelpline.com.au
MensLine Australia – 1300 789 978 or mensline.org.au.