A perfect storm of errors meant Darren was placed in an unsafe cell. He died two days later

The Guardian

13-06-2025

Warning: this story contains descriptions of self-harm and some readers might find it distressing.
When Darren Brandon was detained at Melbourne assessment prison, a perfect storm of missed paperwork and a lack of clear intake procedure between police and the jail meant he was assessed as being low risk of self-harm.
This could not have been further from the truth, according to his brother Steve.
Darren lived with a serious brain injury after a motorcycle accident. It had left him with memory problems and bouts of depression. The family home where he lived had been sold after the death of his mother and Darren was between accommodation. 'Everything in our family just went upside down,' Steve tells Guardian Australia.
In June 2018, when he found out Darren had been picked up by police, Steve says he and his father thought, 'Look, at least he's safe. He's not sleeping in his car on the street somewhere. He's safe. He's in care.'
But the 51-year-old was placed in a cell with a known hanging point and self-harmed the next morning. He died in hospital two days later.
Darren's death is one of at least 57 across 19 Australian prisons from hanging points that were known to prison authorities but not removed, as revealed by a Guardian Australia investigation.
But his story also exemplifies what experts say is the broader story behind Australia's hanging cells crisis.
None of the 248 deaths examined by the Guardian could merely be blamed on the presence of a ligature point. In most cases, those prisoners' placement in an unsafe cell was just the final failure in a litany of them.
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The investigation has also revealed repeated failures to properly assess, review or treat inmates with mental ill health, meaning their suicide risk was either missed or not properly mitigated.
Of the 57 deaths, Guardian Australia has identified 31 cases where inmates who had been previously deemed at risk of suicide were sent into cells with known hanging points. There were 13 cases where inmates who had previously attempted self-harm in custody were sent into such cells.
Guardian Australia has spent five months investigating the deadly toll of Australia's inaction to remove hanging points from its jails, a key recommendation of the 1991 royal commission into Aboriginal deaths in custody.
The main finding – that 57 inmates died using known ligature points that had not been removed – was made possible by an exhaustive examination of coronial records relating to 248 hanging deaths spanning more than 20 years.
Reporters combed through large volumes of coronial records looking for instances where a hanging point had been used repeatedly in the same jail.
They counted any death that occurred after prison authorities were made aware of that particular hanging point. Warnings were made via a prior suicide or suicide attempt, advice from their own staff or recommendations from coroners and other independent bodies.
Guardian Australia also logged how many of the 57 inmates were deemed at risk of self-harm or had attempted suicide before they were sent into cells with known hanging points.
In adherence with best practice in reporting on this topic, Guardian Australia has avoided detailed descriptions of suicide. In some instances, so that the full ramifications of coronial recommendations can be understood, we have made the decision to identify types and locations of ligature points. We have done this only in instances where we feel the public interest in this information being available to readers is high.
In one 2018 New South Wales case an inmate known only as GS had warned officers he wished to kill himself, begged for psychiatric review for months, and was placed into a cell at Goulburn jail with a hanging point that had been used in five previous hanging deaths. That ligature point has since been covered.
In another, an inmate assessed as having a high chronic risk of self-harm, and who had attempted suicide months earlier, in 2007 was placed into a cell at Sydney's Long Bay jail with what a coroner described as an 'obvious hanging point'.
Staff at Arthur Gorrie correctional centre in Brisbane were told that an inmate had 'expressed an intention to commit suicide by hanging if the opportunity arose'. In October 2007 that inmate was placed into a medical unit that contained an obvious hanging point that had been used by another inmate in an attempted suicide just two months earlier.
The hanging point was allowed to remain, despite one guard telling his superiors it needed 'urgent attention before we do have a suicide hanging'.
The overwhelming majority of hangings from known ligatures points involved inmates on remand. Thirty-six of the 57 inmates were on remand, or awaiting trial or sentencing, which is known to be a time of elevated risk for mental ill health.
Most people who experience incarceration have mental health problems but investment in prison mental health care is 'woefully inadequate', according to Stuart Kinner, the head of the Justice Health Group at Curtin University and the Murdoch Children's Research Institute.
The fact that prisoners do not have access to Medicare 'is a somewhat perverse situation', Kinner says. 'We have a system that concentrates a very high burden of mental health issues and simultaneously almost uniquely excludes those people from a key source of funding for mental health care.'
It is unlikely that Australia will ever be able to make all areas in all prisons 'ligature free', he says. 'Therefore, we don't just prevent suicide by removing ligatures, we prevent suicide by providing care and connection.'
Ed Petch led the State Forensic Mental Health Service in Western Australia before returning to clinical work as a psychiatrist in Hakea – the state's main remand prison.
He says that while the removal of known ligature points is important, improving access to health services should be the primary focus, in and out of prison. 'We had more mentally ill people in the prison than Graylands hospital,' he says, referring to the state's main mental health hospital. It has 109 beds. Hakea housed 1,143 men in mid-2024.
Between 2018 and 2023, Petch says he saw more than 12 people every day. 'They weren't adequate mental health evaluations,' he says. 'It was quick in, see what the people are like, decide what treatment to give them and see them in a few weeks' time, if I was lucky.
'The rate of mental illness – acute mental illness and psychosis and depression and loads of mental health disorders – was absolutely vast.'
A scathing report published in February by WA's Office of the Inspector of Custodial Services emphasised that Hakea is overcapacity and a prison in crisis. After a 2024 visit, the inspector, Eamon Ryan, formed a view that prisoners in Hakea were being treated 'in a manner that was cruel, inhuman, or degrading' and noted suicides, suicide attempts and assaults.
There were 13 attempted suicides in the first quarter of that year, the same number as took place in the whole of 2023. Physical and mental health services 'were overwhelmed', with a nurse-to-prisoner ratio of approximately one to 86, and only three full time-equivalent psychiatrist positions for the state's entire prison system.
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Often the most severely mentally ill people are swept up by police, Petch says. 'The courts can't send them to hospital because they are full – or too disturbed – and cannot release them to no address or back to the streets so have no option but to remand them into custody where it's assumed they'll get the care they need. But that assumption is quite often false.'
The WA Department of Justice said it was 'expanding the range of services provided to meet the needs of an increased prisoner population, including those with complex mental health issues'. This includes 36 beds in a new mental health support unit.
A statewide program to remove ligature points had been running since 2005, a spokesperson said.
Experts largely agree that a focus on hanging points, at the expense of all other problems, would be dangerous. Programs to modify cell design are expensive and can leave rooms inhospitable and cold, something that in turn may cause a deterioration in inmates' mental health.
But Neil Morgan, a former WA inspector of custodial services, says a balance must be struck.
'I came across examples where changes were being made to cells … where the new beds were riddled with hanging points,' he says. 'Now that struck me as absolutely ludicrous in this day and age. Changes were only made after I raised my concerns.'
Darren Brandon was a brilliant mechanic before his brain injury, Steve says. He had a coffee machine at his workshop and loved to host visitors and chat. 'He worked on Porsches and BMWs, all the high-end stuff,' he says. 'But he could work on anything.'
But the motorbike accident hit him hard. The coroner noted his repeated attempts at suicide and self-harm.
'The up and down, the depression – this was the side-effects of his brain injury,' Steve says. '[Some days] he could go back to being like a standup comedian. I mean, he was so sharp and just witty and funny.'
After the family home was sold, Darren began a residential rehabilitation program but left, and was reported to police as a missing person. When he went to a police station accompanied by a case manager, he was taken into custody due to a missed court date.
Prison staff were not fully aware of his history of self-harm. This meant he was given a lower risk rating and was placed in a unit with a known hanging point and which was not under hourly observation.
The coroner overseeing the inquest found that the design of Darren's cell was the 'proximate cause' of his death. He wrote that the 'rail inside the cell was known to be a ligature point well prior to Darren's death'.
A spokesperson for Victoria's Department of Justice and Community Safety said the state's prisons had strong measures in place to reduce self-harm and suicide, including the use of on-site specialist mental health staff and training in the identification of at-risk inmates.
Inmates are now required to undergo a mental health risk assessment within 24 hours of arriving in custody and are seen by a mental health professional within two hours of being identified at risk of self-harm. The state government has aimed to build all new cells in accordance with safer design principles for more than 20 years.
'The Victorian Government continues to invest in modern prison facilities to improve the rehabilitation and safety of people in custody,' the spokesperson said.
Steve and his wife, Annie, keep a photo of Darren on their fridge. There are so many what-ifs. So many moments when something could have gone differently.
'If he'd been assessed properly, they would have said, 'Oh, this guy's had some attempts in the past, brain injury … OK, let's put him in a safer spot where there's no ligature points,'' Steve says. 'He'd still be alive.'
Annie says: 'The system certainly failed him, and us as a family.'
In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org