The troubled relationship between custodial authorities and prisoners’ families has continued to draw criticism at deaths in custody inquests, with numerous coroners finding deaths may have been avoided had structures been in place to help family members assist in the prisoner’s care.

A Crikey analysis of the findings of inquests completed in the past decade has revealed that in at least 11 deaths, coroners commented on the failure or inability of family to successfully communicate to prison authorities information — such as the ending of a relationship or marriage — that would impact the inmate’s risk of self-harm or suicide.

In several cases, the inmate had explicitly told a family member or partner that he or she intended to suicide but that information was not communicated to custodial staff. In two cases — Desmond Walmsley, who died in 2007, and Larna Ryan, who died in 2005 — family members went to considerable lengths to alert custodial authorities of suicide threats, but the response from authorities was haphazard and, ultimately, insufficient.

Corrective Services insisted at two separate inquests in 2007 — those of Yuri Azar and David Porter — that it had commissioned a working party to consider mechanisms through which next of kin could relay relevant information that may impact on prisoner risk assessment. Deputy state coroner Carl Milovanovich noted with approval the department’s actions, in both cases stopping short of making formal recommendations pending the outcome of the working party’s report.  His written findings request that the deliberations of the working party be made available to the Office of the State Coroner “in due course”.

The NSW Office of the State Coroner could not locate any report or other document outlining the status or results of the working party. Corrective Services refused to answer Crikey’s questions about the working party.

William Beale, a former investigator with Corrective Services NSW’s internal investigations unit, led the department’s internal inquiry into the death of Yuri Azar. He says his recommendation that custodial staff work with family in cases where prisoners were known to be a suicide risk was ignored.

“Here was a guy who was a foreseeable candidate for suicide. He was an ongoing risk but he wasn’t treated; he wasn’t on any program. It had been identified in his case that if the support of his family were withdrawn, he’d be likely to commit suicide. His wife left him,” Beale says.

“[M]y recommendation was that in cases like that somebody should have taken the initiative to say [to his family]: ‘Look, we’re concerned about him, he’s relying on your support now. We can’t tell you to support him’ — you can’t tell his wife not to leave him — ‘but if you do leave him, let us know, please’.

“I put that report in and I know that nothing happened [to implement my recommendations].”

Catriona McComish, a former senior assistant commissioner with Corrective Services NSW, says “every barrier is put in the way” of families seeking to communicate with custodial staff, whether seeking or wanting to share information.

“Prisons really operate still so much as a complete removal from society and, basically, family and community are viewed as a problem … [and] I don’t think it has to be that way,” she said.

“Certainly, as a family member, if you were trying to ring the prisons, it’s very difficult to find someone that you can pass a message on to or talk to. You just need to talk to family members of prisoners [who have], for example, mental health issues and you hear the incredible effort that they make to try and get information through so that there’s an understanding of what might happen or to warn about vulnerability. It’s very, very difficult.”

McComish, who also served as the Department’s Director of Psychological Services for five years, says family support and interaction can play a powerful role in prisoner rehabilitation: “It would make an enormous difference not just to the safety of prisoners and their well-being, but also to their eventual transition back into the community if indeed you could maintain those kinds of contacts with family and community.”

The importance of family in the safety and rehabilitation of prisoners was recognised by the Royal Commission into Aboriginal Deaths in Custody. The commission’s final report noted: “The role that corrections officers can play in the management of those at risk should not be overlooked. Of greater importance, however, is the role that members of the inmate’s family could play … It is thus important that efforts be made to encourage the involvement of the families of Aboriginal prisoners in the management of those at risk.”

The report goes on to outline in successive recommendations ways that police and prison authorities should respect and encourage contact family contact with prisoners and detainees. This was particularly important, the report noted, following a death in custody.

Notification of families was particularly problematic before the Royal Commission. Although some officers performed the task of notification “with sensitivity and expedition”, the report noted, many others deserved criticism for their “inhumanity”, such as one officer who insisted that the deceased’s brothers identify his body in the back of an ambulance parked in a street.

It subsequently recommended that notification of death to the family and other nominated persons should be “immediate”: “Notification should be the responsibility of the custodial institution in which the death occurred; notification, wherever possible, should be made in person … At all times notification should be given in a sensitive manner respecting the culture and interests of the persons being notified and the entitlement of such persons to full and frank reporting of such circumstances of the death as are known.”

Yet notification problems have continued to cause grief for families. In 2006, the Department of Corrective Services told the mother of Long Bay prisoner Craig Behr that her son had committed suicide. In fact, Behr had been violently murdered in his cell, kicked to death by an inmate who had repeatedly warned prison staff he was having homicidal thoughts and should not by placed in a cell with anyone.

“At first the Department of Corrective Services representative told us that Craig had committed suicide — later we learnt from the police that he had been murdered. Then we could get no further information,” Janet Behr told the court during the trial of her son’s killer in October 2006.

The family of Mark Holcroft — a minimum-security prisoner who died in the back of a prison van in August last year — say they found out about his death five days later from investigating police. Holcroft, who was serving seven months for a drink-driving offence, was denied his heart medication for the six-hour trip Bathurst to Mannus Correctional Centre near Tumbarumba. The banging and shouting of seven fellow inmates were ignored by the guards, who did not stop the van until it had reached its destination.

Holcroft’s sister, Liane Curry, told Lateline that when she called Corrective Services to inquire about her brother, she was informed that he could not be located in the system. “It wasn’t until the next day after I’d made those phone calls that I was received a call from the detective to say, ‘Oh, your brother’s died of a heart attack we think. Oh, and the autopsy was yesterday’.”

In the January 2003 case of Aboriginal man Jason Knight — who died in NSW prison custody 18 days after he should have been released — Corrective Services waited two months and 19 days to notify the family and the coroner of the error.

“To be told the accurate and authoritative facts of the death is very, very crucial,” says Charandev Singh, a human rights advocate and paralegal who has worked on deaths in custody for almost 20 years. “If … you’ve been lied to about how your son was killed, how could you possibly have faith in the investigation? How could you possibly have faith in what Corrective Services and the police are telling you after that point?”

This is the seventh in a series of case studies and investigative reports into prison deaths. Next week, how inappropriate cell placement contributed to 20 deaths in NSW prisons.