For months after her oldest son was found dead in a prison cell at Kirkconnell Correctional Centre near Bathurst, Lynette Shipley was haunted by a recurring nightmare.

“Adam was on the bed, holding the bed rails and [falling] backwards, and as he let go he screamed: ‘Mum, I changed my mind!’ I dreamt that for so long,” she said.

Aboriginal inmate Adam Douglas Shipley was taken into custody on Christmas Eve 2006, after breaching his parole conditions by failing to attend a psychologist’s appointment. Five months later, on May 21, 2007, he was found dead in his cell, hanging by the neck at the end of his bunk bed.

Lynette wears the memory of her son’s death as much in her limpid expression as in her listless voice. The 55-year-old mother of four says she still can’t bring herself to leave the house some days, nearly five years later.

“That’s Adam up there,” she said, pointing to a primary school photo of a handsome kid with shining eyes and a cheeky grin.”You can just tell by the face he was a charmer… Even when he was down and out, he always had a smile for me.”

Described at his inquest as “high maintenance” but likeable, “Shippo” — as he was known to his fellow inmates — was a diagnosed paranoid schizophrenic with a history of self harm and suicidal thoughts. Dogged throughout his school years by dyslexia but a gifted artist, Shipley’s suicide note bears a simple drawing of an eye gazing straight ahead as four large tears stream down the page. It reads: “I carn’t do this anymore! I’m REALLY SORRY!!!! Have MERCY Lord! To much Pain 4 2 long! I’m not wanted or inportant to anyone! JUST A WAST of space, SHIT! Lonelyness + Emptyness is a killeR! it Doesn’t matter anymore.”

At the 2009 inquest into Shipley’s death, NSW State Coroner Mary Jerram found the Department of Corrective Services had failed to exercise proper duty of care at pivotal points during his custody.

The first failure was the absence of any psychological treatment plan. “There is simply no evidence to indicate that the relevant DCS [Department of Corrective Services] or Justice Health staff turned their minds to the need for a coordinated, ongoing and proactive management of Adam Shipley,” Jerram wrote in her findings.

The next two failures — to keep adequate records and to exchange vital information with relevant staff — occurred when Shipley’s first case officer neglected not only to document any of Adam’s self harm threats but also to communicate “significant observations and interaction[s]” to Shipley’s next case officer. This meant his second case officer did not have access to a comprehensive medical history — another failure on the part of the Department.

Inappropriate security classification and cell placement was the Department’s fifth failure. Despite Shipley’s long history of psychological and emotional disturbance, and his constant threats to self harm, the Department granted his request for placement in a minimum security facility with reduced supervision and relatively easy access to numerous hanging points, as well as ropes, cords and other tying devices. It also granted his request for a single-person cell, contravening its own guidelines for the management of “at risk” inmates.

Each link in this chain of failures brought Shipley one step closer to death.

“As a mother it’s your job to keep your child safe and if [your son] is dead, you’ve failed,” Lynette said. “[But] if they hadn’t just plucked him off the street for no reason and then, knowing his history, given him opportunity and ammunition, it wouldn’t have happened.”

A flash of fury brings life to her reddened eyes.

“If my kids didn’t do what they were told, they would have got punished for it,” she said. “These people haven’t done what they’ve been told so many times, like, it’s gone way past time out. They need punishing.”

Shipley’s death is one fragment of a bigger story — as Crikey has been documenting as part of a weekly series — involving seven prisoners linked by a lethal chain of negligence (view the raw data here), bureaucratic bungling and failed policies. A quarter of a century separates the first death from the last, yet the breaches of procedure and failure to exercise duty of care are almost identical in each.

The Royal Commission into Aboriginal Deaths in Custody first documented this pattern of failures in its report into the death of Malcolm Smith, who died in 1982 after stabbing a paintbrush so deeply into his left eye that only the metal sleeve and bristles were protruding. Smith’s was one of the 99 Aboriginal deaths investigated by the Commission between January 1, 1981 and May 31, 1989.

After the release of the Commission’s report into Smith’s death, the government assured the public that the system had improved. However the death of Peter Williams five years later, in circumstances chillingly reminiscent of Smith’s, suggested a different story.

Then, in 1991, the Commission delivered its final report — a damning assessment of the social, economic and political conditions underlying indigenous overrepresentation at all stages of the criminal justice system. It made 399 recommendations, 45 of which urged sweeping changes to custodial health and safety provisions.

“We found many system defects in relation to care, many failures to exercise proper care and in general a poor standard of care,” the Commission reported. It reserved its harshest criticism in relation to prison custody deaths for the Prison Medical Services.

By 1998, the NSW government claimed to have implemented the overwhelming bulk of the Commission’s recommendations. But a Crikey analysis of NSW Coroner’s annual reports published between 2001 and 2009 has uncovered five deaths — the first occurring in 1999, the last in 2007 — that follow a pattern of failures almost identical to those leading to Smith’s and Williams’ deaths more than 20 years ago.

“There’s a vast gulf between what governments say has been implemented and what has actually been implemented on the ground, and you see the gulf opening up in inquests,” said Charandev Singh, a veteran paralegal and human rights advocate of 20 years standing. “I work on deaths in custody right across the country … and the similarities in the causes and the conditions of deaths in custody are just astonishing.”

Each of the five men — Adam Shipley and Desmond Walmsley, both of whom suicided in 2007; Scott Simpson, who hanged himself in 2004; Mario Navascues who suicided in 2003; and Eddie Russell who died in 1999 — had a long history of psychiatric illness and self harm; four had known suicide attempts. The inquests into each of their deaths documented a litany of failures in addition to the glaring absence of any ongoing psychiatric treatment: inadequate record keeping, inadequate or non-existent health assessments, failure to check prison and medical records, inappropriate cell placement or security classification, and failure to communicate vital health and safety information to relevant staff. Coroners handed down formal recommendations in all five cases, yet these same failures continue to claim lives.

Catriona McComish, a former senior assistant commissioner with Corrective Services NSW, says the problem goes beyond the provision of care in prisons, to the heart of the prison system itself. She maintains it is impossible to keep inmates safe in an environment that prioritises security and confinement.

“The prison environment is about security and it is also punitive, so things like the person’s [health or mental] state are not going to be given priority,” McComish, who left the Department in 2006, told Crikey.

“It doesn’t matter, really, how much policy you have. While the authority and the power is invested in the prison system rather than the health system or health professionals then there’s going to be lapses and there’s going to be deaths.”

Prison medical services are now run by a section of the NSW Health Department called Justice Health, rather than by Corrective Services. However, according to Michael Levy, who worked in NSW prisoner health for more than a decade before becoming medical director at ACT Corrections Health, prisoner health is still hostage to security concerns.

“There is, at a deep policy level, an accommodation which is much more health accommodating custodial than custodial accommodating health,” he said. “The power of custodial, with its budget of a billion dollars, against the budget of Justice Health, which is somewhere between $2 million and $3 million, I think pretty much says where the power is.”

The Royal Commission recognised that when a person is removed from society and deprived of their liberty for whatever reason, the responsibility of the state to exercise a duty of care and prevent harm to that person is heightened.

“It is settled in law that a custodian owes a duty to a prisoner to take reasonable care for his or her safety,” Commissioner Elliott Johnston wrote in the Commission’s final report. “The existence of the duty of care is fundamentally associated with the fact that, by definition, a person in custody has been taken from his or her ordinary environment, cut off from normal sources of assistance … and made dependent for all requirements upon the custodial authority.”

Noting that the prison population had “distinct health needs”, including a higher than average rate of psychiatric illness, reactive depression, stress and trauma, the Commissioners maintained that “the duty of care owed by custodians … extends to the provision of proper medical care”, whether requested by the prisoner or not.

Around 42% of the NSW prison population (about 4600 prisoners) have mental health disorders, according to the latest figures from Corrections Health (now Justice Health). Justice Health concedes that soaring rates mental illness among inmates presents challenges, but insists the standard of its mental health services are “world class”.

“Significant improvements in Justice Health services have occurred, with the opening of Mental Health Screening Units for both men and women and the recent opening of the first high secure stand alone Forensic Hospital [a hospital for those found not guilty by way of mental illness] in NSW,” the Department told Crikey in an email statement. “These improvements have resulted in a marked decrease in the suicide rate and greater numbers of people in custody receiving mental health care. These initiatives provide a comprehensive world class mental health service for those who find them incarcerated in the NSW correctional system.”

The Mental Health Screening Unit for men opened at Silverwater Metropolitan Reception and Remand Centre in February 2006. Yet Shipley died in May 2007 and Walmsley in September 2007.

The forensic hospital opened at Long Bay in February 2009, however its 135 beds are reserved for the state’s forensic patients, who number around 340. Sentenced or remand prisoners with mental illnesses must make do with desperately overstretched mental health units.

Scott Simpson — a severely disturbed man who should have been in a forensic hospital, not a prison — spent the last 10 weeks of his life alone in his cell for up to 22 hours per day. Just seven hours before his death in 2006, the minor charges for which he had been taken into custody more than two years earlier were withdrawn. Nine weeks earlier he had been found not guilty by reason of mental illness of the murder of his cellmate Andrew Parfitt.

The cell in which he hanged himself was the very same cell in which he had previously attempted suicide. He died having spent the past two years and two months, except for two short periods, in solitary confinement.

Scott’s mother, Terri, described how the denial of treatment and support in prison destroyed her son. “My son Scott had never backed down or ever given up on anyone or anything before his death. He had the most devilish sense of humour along with a beautiful smile and a beautiful soul later beset by torment and anguish,” she wrote in a letter to then deputy coroner Dorelle Pinch, who investigated Scott’s death.

“[T]he last visit I had with Scott … [h]e was crying and desperate to get some sun on his face before he was locked back in his dark segregation cell.”

Simpson’s death — and the six others like his — is a stark reminder of the blurred line between victim and offender.

“My son’s death has taught me one thing that I will never forget and that is any person can be broken and defeated by a system that punishes rather than corrects,” Terri wrote. “Scott was not just my son; he was my life… I can only pray that another family does not have to live through the nightmare that I live with every day. It just has to stop… I need these deaths to stop.”

*This is the third in a series of case studies and investigative reports into prison deaths. Next week, how mental health checks still failed prisoners who committed suicide in NSW jails.