After Chelsea's mother died in an unsafe cell the coroner delivered a scathing message

The Guardian

10-06-2025

Warning: Aboriginal and Torres Strait Islander readers are advised that this article contains images and names of Indigenous Australians who have died. This story contains descriptions of self-harm and some readers might find it distressing.
In November last year a coroner issued a scathing message to the Western Australian government.
In a report handed down into yet another suicide in the state's jails, Michael Jenkin upbraided the government for its 'painfully slow progress' on removing deadly hanging points from prison cells, calling it 'a serious and unacceptable blight'.
To drive that point home, he then cut and pasted two sentences:
This Court cannot continue to make these types of recommendations in the face of ongoing prisoner deaths by hanging. The Department must now take urgent action to address this appalling situation.
Word for word, they were the same two sentences he had used in a coronial report into a prison suicide in November 2022, and then again in March last year, while presiding over an inquest into the death of Suzzanne Davis, a 47-year-old Torres Strait Island woman who died by suicide while on remand at Melaleuca women's prison in 2020.
Suzzanne's daughter, Chelsea Fisher, spoke to the Guardian as part of a five-month investigation into hanging deaths in Australian prisons, which found 57 deaths across 19 jails from ligature points that were known to authorities.
Over and over, coroners made recommendations after many of these deaths that state governments should work quickly to remove these points.
Again and again, governments and prison authorities failed to act.
'You publish [recommendations], you follow them up by saying, 'Has anything happened?' You get fobbed off,' says Michael Barnes, a former state coroner in Queensland and New South Wales. 'And the authorities, private operators – there's no compulsion on them to justify their inaction.'
Coroners in all states have limited power to ensure this work is carried out.
After the death of a prisoner at south-east Queensland's Borallon correctional centre in 2004, Barnes recommended that any exposed bars in cells be covered in mesh. In 2011 another man killed himself in the same manner at Borallon.
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Barnes said such cases made him question the 'efficacy' of the coronial system, with coroners unable to scrutinise whether their recommendations have been properly acted on – except during the next inquest after yet another death.
In Chelsea's Perth home, the photos she still has of her mother show a woman with a wide, irresistible smile – piggybacking her daughter; leaning over her shoulder as she cuts a birthday cake covered in sprinkles.
Suzzanne's life was troubled on the outside but in prison she was a nurturing figure, dedicating herself to exercise, art and gardening. When Chelsea was little, she would visit her once a week in the jail, where everyone from the guards to the other inmates loved her.
'She was a role model in there,' Chelsea says. 'That's what all the girls said when she passed away. She was really caring … She was just a good person.'
Jenkin found the mental health care Suzzanne received was 'inadequate' and, despite a 'chronic, long-term risk of self-harm', the prison failed to place her in a cell that was fully ligature-minimised – a situation he said had to change as an 'absolute priority'.
The inquest that made this finding was not held until 2024 – four years after Suzzanne's death.
The failure to hold timely inquests means that obvious hanging points are sometimes used again before the inquest into the first death is completed. After a 2017 hanging from a cell window in the Darcy unit of Sydney's Silverwater jail, it took five years for the coronial investigation to be completed. By the time the court recommended the ligature point be addressed, another inmate had used it.
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.
Even four years after Suzzanne's death, according to the coronial report, no ligature minimisation work had been carried out at Melaleuca.
For Chelsea, the wait for her mother's inquest meant years of anxiety. 'I just wanted it to be over with,' she says. 'I couldn't start to properly heal until afterwards. Just the waiting, wondering for that long.'
Coronial delays are not limited to WA, which claims to have improved its backlog. In a 2022 NSW parliament report on the coronial system, the state's Bar Association described the delay of death-in-custody inquests as 'chronic'.
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A former NSW deputy coroner, Hugh Dillon, estimates there is a backlog of about 130 mandatory inquests into deaths in custody or deaths during police operations. His analysis suggests that in 2024 more than 70% of published inquests took more than three years from the date of death to complete.
'The ship is sinking,' Dillon said of the NSW coroners court. 'They're bailing it out as fast as they can. But they're going down with the ship.'
A NSW Department of Communities and Justice spokesperson said it had provided funding for two temporary coroners for 18 months to assist with the backlog. The two new coroners will be appointed in coming months, the spokesperson said.
In WA, Guardian Australia found repeated 'strident' warnings in more than two decades of coronial findings about the need to address hanging points, alongside pleas for better staffing and healthcare.
In his findings on the death of Suzzanne Davis, Jenkin noted that in 2023-24, only $1.645m was allocated by the government for ligature-minimisation work across the state's adult prison system.
This funding was, by the department's own analysis, 'only sufficient to refit approximately 8 cells to be fully ligature minimised', he wrote.
In 2024-25, the allocation was even more 'parsimonious', he said, with $1.137m set aside.
Peter Collins, the director of legal services at the Aboriginal Legal Service of Western Australia, says the situation is maddening. 'It's really easy for governments, especially in this state, to simply ignore the recommendations of coroners such that coronial findings just gather dust on a bookshelf.'
A 2023 report by the state's Office of the Inspector of Custodial Services found that the Department of Justice 'frequently' closed its responses to coronial reports without fully implementing their recommendations. The report found one prison had increased its number of ligature-minimised cells, but it was due in large part to the prison's expansion and not the retrofitting of old cells.
On a visit to Broome regional prison, the inspector found at least 40 ligature points in the minimum-security area, despite the coroner recommending a ligature-minimisation program after a 2015 death.
The almost 60 deaths from known ligature points identified by Guardian Australia comes as no surprise to Megan Krakouer, a Menang woman of the Noongar nation and the director of the National Suicide Prevention and Trauma Recovery Project.
She has attended many inquests into the deaths of First Nations people in custody in WA and has seen first-hand the government's failure to act on coroners' recommendations.
'They just make these recommendations one after the next, after the next, after the next,' she said. 'You can see the frustrations but the bottom line is the coroner can only do so much.
'It becomes extremely devastating for the particular families because then they carry this hurt … and yet there's no accountability whatsoever.''
The Western Australian Department of Justice said it had undertaken a comprehensive hanging point removal program since 2005. It also completed an audit in 2023 that confirmed all cell furniture and fixtures at Melaleuca Prison are 'ligature-minimised compliant'.
A spokesperson said that it was 'not possible to achieve the complete elimination of all ligature points' but priority was 'given to facilities with the highest risk and need'. The state is expanding services for those with complex mental health issues, including by building dedicated therapeutic accomodation and employing specialist mental health staff, the spokesperson said.
For Chelsea, the lack of answers still weighs heavily. She is haunted when she hears about each new death in custody.
'That's why I'm just so angry at everybody, I guess,' she said. 'I don't understand why it had to be like this. It just makes no sense, cause it was pretty black and white to me.'
In Australia, the crisis support service Lifeline is 13 11 14. Indigenous Australians can call 13YARN on 13 92 76 for information and crisis support. Other international helplines can be found at befrienders.org