Jason and Luke died in the same way as dozens of others. Why did authorities fail to act?

The Guardian

4 hours ago

Warning: this story contains descriptions of self-harm and some readers might find it distressing.
They found Jason Muir before the sun rose over Arthur Gorrie prison.
It was the overnight shift, just past 4am.
A lone guard was patrolling the corridors, counting sleeping inmates, when he stopped outside cell 22.
His colleagues had looked in on Jason, the cell's only occupant, just three hours earlier, without issue.
Now something was wrong. The window had been covered from the inside.
Jason, 36, was known to have a history of suicidal ideation. When he arrived at the Brisbane prison, he was marked at risk and placed in a safer cell under regular observations, before being downgraded and placed back in the mainstream population.
His family were worried about him. His mother had been visiting regularly and had noticed a deterioration in her son's mental health.
Darren Muir, Jason's older brother, says she loved her youngest son dearly. Darren did too. He describes his brother as a kind-hearted, reserved kid who fell in with a bad crowd when the family moved to a rough part of Brisbane after their dad died suddenly when Darren was 11.
'We were both rascals,' Darren says. 'I loved the bloke.'
The guard outside Jason's cell shifted his gaze upwards.
Above the door something had been tied to a set of exposed bars that covered a small ventilation window – a common design feature in Arthur Gorrie's older cells.
The bars should not have been there.
They had been used in four hanging deaths in the past seven years, the latest just two months earlier.
State coroners had repeatedly and explicitly told the Queensland government to urgently remove them.
Eighteen months earlier one coroner, Michael Barnes, had left little room for equivocation after the death of another man in the prison.
He told the state government to 'immediately make available sufficient funding to enable the removal of the exposed bars in all cells at the Arthur Gorrie Remand and Reception Centre'. Almost two years before Jason's death, after another hanging death from the bars, the same coroner had said they 'could easily be covered with mesh', a fix that would both remove the hanging point risk and solve the authorities' concerns about a loss of ventilation to cells.
The bars remained.
They remained in the lead-up to Jason's 2008 death and they remained after the guards cut him down.
They remained after the coroner tasked with investigating Jason's death lamented that she had been warning about this particular hanging point since her first inquest in 2001.
They remained after two separate hangings in 2010, one by an inmate who had told prison staff he had thought of hanging himself from the bars. They remained after hangings in 2018 and 2019, and were last used in a hanging in 2020.
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Guardian Australia has established that the bars have been used in 10 hanging deaths over almost two decades.
And this isn't just happening at Arthur Gorrie.
Over the past five months the Guardian has investigated 248 hanging deaths in prisons across the country, reviewing coronial reports for cases where the same ligature point has been used repeatedly or where it has been used after authorities were warned to remove it.
The investigation reveals a shocking death toll from continued inaction, more than 30 years after state governments pledged to remove hanging points in the wake of the royal commission into Aboriginal deaths in custody.
Fifty-seven inmates in 19 prisons have hung themselves from hanging points known to authorities but not removed, typically due to funding constraints.
At Goulburn jail, for example, six inmates were able to use the window bars to hang themselves over 20 years before the state government finally covered them with grilles.
At Adelaide remand centre, four inmates were able to hang themselves from beds after the state government was told to remove them or to minimise their ability to be used as ligature points.
At least five prisoners have hung themselves from fixtures at Hakea prison in Western Australia, despite warnings to the state government as early as 2008 to address obvious ligature points.
In one case, after the hanging death of a young Indigenous man at Tamworth prison, the New South Wales government blamed the jail's 'heritage' listing for its slow progress in removing hanging points.
When it was ordered to audit Tamworth jail for other obvious hanging points and remove them, it told the coroner it could find none.
A visit by the NSW prison inspector a year later revealed 'there were still ligature points in each cell', including ones that had purportedly been removed.
In dozens of cases, prisoners deemed at risk of suicide and inmates who had attempted self-harm in custody were sent into cells with known ligature points.
One inmate who had 'expressed an intention to commit suicide by hanging if the opportunity arose' died after being sent into a part of Arthur Gorrie prison where another prisoner had tried to hang himself from an obvious ligature point just two months earlier. That ligature point remained even after a guard warned his superiors that it required 'urgent attention before we do have a suicide hanging'.
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.
The findings have shocked Barnes, now the NSW crime commissioner, who says they call into question the effectiveness of the coronial system – a system to which he has devoted much of his life.
'It comes down to the fact that there isn't a public outcry about these things,' he says. 'If it were happening to another cohort, you can imagine there would be a significant outcry but because it's prisoners, you know, people think it's all part of it.'
When guards searched Jason's cell they found two letters. One to his mum and one to his brother.
Darren was staying at a property outside Bundaberg, a few hours north, when the news came through.
He remembers he was out in the yard when a friend handed him the phone.
'I can remember it clear as day,' he says. 'You can imagine, it was the worst day of my life.
'They told me he was dead and I passed out.'
In the 17 years since, Darren was never told that the hanging point had been used before and after his brother's death.
When Guardian Australia shows Darren the names of those who died using the bars, before and after his brother, his response is scathing.
'There is no care whatsoever,' he says. 'They don't care what they're doing. To me, it looks like a culling centre.'
The Queensland government declined to answer specific questions about Arthur Gorrie prison and would not say whether the ligature points have now been removed. A spokesperson said the government 'takes the safety and wellbeing of prisoners in custody very seriously'.
There's a shrine to Luke Rich in his family's living room in Taree.
His white hard hat sits on top of a toolbox that contains his ashes. It's covered in stickers for the Roosters rugby league team. His old vape is there, tucked inside one of his favourite sneakers.
Each part of the house has been touched by him, from the dark wood panelling he helped his father restore to the kitchen shelves and the chicken coop he built for his mother, Karen Reid.
No one gave hugs like Luke did, Karen says. He was big and tall and affectionate. 'Treat me like an egg,' she'd tell her boys. 'I'm not a hard-boiled egg and I crack very easily.'
His father, Garry Reid, says Luke was his little shadow as a child. Garry would have to watch where he stepped to avoid tripping over him. When he was full grown and over six feet tall, he'd pick up Garry – not a small man himself – and kiss him on the forehead.
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The pair shared a love of rugby league and, when Luke started getting into some trouble as a teenager, Garry took him out on jobs as a carpenter. Eventually Luke became a site foreman for a construction company in Canberra.
After he left home he regularly called his mum. 'You had to speak for no less than an hour,' Karen says, laughing. 'Otherwise I'd be accused of having something better to do.'
In February 2022 Luke died, one day after he was remanded in custody at the Alexander Maconochie centre in the Australian Capital Territory. He had used a ligature point on the cell door – a point the prison had been warned could be used for that purpose seven years earlier. He was 27.
'At the time of Luke's death, the Territory chose to accommodate newly arrived detainees in a physical environment they knew to be, in one important aspect, unsafe,' the coroner Ken Archer said in his findings.
In 2015 the prison's facilities management team suggested that the doors be reviewed due to the possibility a ligature could be tied to them.
According to an investigation into Luke's death by the ACT custodial inspector, the cost of replacing the doors was estimated to be $610,000. Due to budget constraints, this was not done.
The investigation found that ACT corrective services 'was aware of a serious design fault in the rear cell doors which had been known since 2015' and had failed to properly observe Luke, among other concerns. It recommended immediate action be taken to fix the doors.
A spokesperson for ACT Corrective Services said upgrades to the doors had been completed in 2022 and a further review of the doors was under way.
The government had also taken steps to train staff in suicide prevention and response and to remove ligature points from furniture in the jail, the spokesperson said.
The family sat through the entire coronial hearing into Luke's death. Karen made a statement at the beginning, imploring that 'those responsible for looking after and keeping my son safe acknowledge their faults, and, above all, fix the doors so that no other mother and family has to go through this pain, heartbreak, anguish'.
She says: 'The purpose [of] that statement was for them to see that Luke was a person, not a detainee and not a number.'
To hear that the cost of replacing the doors had a dollar figure was too much to bear. 'You sit there and you tell me that you will not and cannot put a price on life,' Karen says.
'Guess what, you did. You put a price on my son's life. And it wasn't anywhere near the value.'
Luke and Jason's stories are mirrored across the country.
In Queensland the warnings about exposed bars were not isolated to Arthur Gorrie.
A 2004 hanging death at Borallon correctional centre prompted a coroner to tell the state government to 'immediately cover with mesh any bars accessible to prisoners in cells'.
Five years after that warning, another Borallon inmate hanged himself from exposed bars above his cell door.
A hanging death at Townsville prison in 2007 prompted a warning that the Queensland government 'immediately' act on hanging points 'including bars' by replacing them with an alternative security barrier such as mesh.
Two more hangings took place from exposed bars at Townsville in 2015 and 2019, roughly a decade after that warning.
At Sydney's Long Bay correctional complex, there were three hangings from window bars in the metropolitan special programs centre, despite a warning in 2007 that the 'obvious' hanging points should be removed.
Four hanging points at Adelaide's Yatala labour prison have been used in 11 deaths, despite repeated calls for their removal.
Australian Institute of Criminology data shows hanging remains by far the most common method of self-inflicted death in custody. The data also shows the total number of prison hangings has crept back up to levels not seen since the early 2000s, with one now occurring on average every three weeks – likely due to the increased numbers of Australians being held in custody.
Considerable progress to reduce the rate of hanging deaths was made between 2000 and 2008. But the data suggests that progress has stalled, remaining largely constant since then.
Barnes, the former NSW and Queensland coroner, says the research is 'overwhelming' that preventing easy access to obvious hanging points is effective at reducing suicide.
Many prisons move at-risk inmates to safer cells, which are more regularly monitored and have fewer ligature points.
But Barnes says identifying suicide risk in a cohort of inmates is incredibly difficult, largely because the entire prison population is at elevated risk. That, he says, makes the removal of the hanging points all the more essential.
'It's very frustrating because you see so much money being spent building prisons and the like, and even new prisons that were being built didn't always eliminate hanging points,' he says. 'When you know that it's such an effective measure to take, it's really mind-boggling that they wouldn't do that.
'For coroners and people involved in suicide prevention, it's extremely frustrating.'
As well as the failure to address ligature points, most cases reveal glaring deficiencies in mental healthcare and conditions in Australian prisons as well as a systemic lack of support and services for people in and out of custody.
Mindy Sotiri, executive director of the Justice Reform initiative, has been campaigning for prison reform for more than 25 years. She has seen first-hand the 'inertia' that prevents meaningful change in this space – driven by public apathy and a lack of political leadership.
'There have been so many people who have been trying very hard to alert corrections of the dangers and the safety concerns for people inside,' she says. 'But there's just inertia on the part of corrections to respond, and such an absence of political will to see this issue as something that should be on the national cabinet agenda.'
The cases investigated by Guardian Australia expose the crisis in stark terms.
In 2015, after a hanging death at Arthur Gorrie, the state government told a coroner it was working to fix up 268 old cells.
Six years later, after yet another hanging death there, the government was asked for an update on its progress. It said it still had 268 older-style cells at Arthur Gorrie to make safe.
Not a single cell had been remediated in the six years between the two inquests.
Guardian Australia approached every state and territory government in the country to ask why known hanging points weren't removed and what was being done to make cells safe.
Every government said they were taking the issue of cell safety seriously and had invested significant funds in refurbishing old cells.
Most also pointed to their attempts to improve the identification of at-risk inmates and provide them with treatment, supervision and monitoring. You can read the full responses from state departments here.
Darren Muir knows first-hand what it's like to be in Arthur Gorrie.
He spent two weeks there, locked in the same cells, with the same exposed bars, that his brother used eight years later to take his own life.
The place nearly sent him crazy, he says.
'I'll give you one word: it's a fucking zoo, mate,' he said. 'That's how primitive that place was.'
Darren says he believes his brother would not have accepted mental health treatment and probably would have found a way to take his life, even if the bars had been removed.
But what he can't abide is the state government's failure to act on repeated warnings to remove the obvious hanging points, including after his brother's death.
'They're more or less handing them the rope,' he says.
In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org