Inquest finds supervision failures contributed to man's suicide death in Canberra jail

A coronial inquest has found gaps in supervision contributed to the death of a 34-year-old man who died by suicide in Canberra jail.

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More than three years later, findings related to the cause and circumstances leading up to his death have been handed down in the ACT Coroner's Court.

The coroner, Lucinda Wilson, said Mr Cordy died because of injuries from a self-inflicted hanging and that unrestricted access to materials used to construct a ligature, combined with a failure to observe him in possession of them, contributed to his death at the AMC.

Ms Wilson further highlighted gaps in mental health services and communication between police, paramedics and Canberra Health Services in the days before his death.

In her opening statement, Ms Wilson apologised for the time taken to deliver the findings and said Mr Cordy's family had shown "great patience".

The coroner acknowledged his parents, brother, the mother of his two children and his close friend who were present in court on Friday, October 23.

Self-harm in police custody, unavailability of court's mental health service

The inquest examined the sequence of events leading up to Mr Cordy's arrest and subsequent transfer to the AMC.

On February 24, 2023, Mr Cordy was accused of stealing a car, ramming into a police vehicle and crashing into a light pole at high speed. He is said to have run from police before he was Tasered and arrested.

Ms Wilson said ACT Policing had created a statutory alert regarding Mr Cordy's mental health state on February 23, 2023 and that this information was not shared with officers who arrested him the next day.

The coroner said Mr Cordy cut his wrist with a knife during his arrest and police officers failed to inform paramedics and medical professionals at Canberra Health Services about the act of self-harm.

"Those medical professionals are likely to have made different medical decisions," the coroner said, adding Mr Cordy's mental health needs were not adequately taken care of in the aftermath of his arrest.

Special magistrate Lucinda Wilson handed down findings from an inquest on the death in custody of Justin James Cordy who died in Canberra jail in 2023. Picrtures by Keegan Carroll, Rohan Thomson

She said neither did Mr Cordy undergo a mental health assessment before his court appearance on Saturday, February 25, 2023 nor did the court benefit from the results of such a psychological assessment in case had applied for bail.

This was because the mental health court liaison service only operated on weekdays.

The coroner said the "unsatisfactory" police conduct and gap in service availability were serious public safety issues, and recommended that Canberra Health Services consider extending its service hours.

Ms Wilson explicitly found these shortfalls did not cause or contribute to Mr Cordy's death.

Jail criticised for access to ligature-making items, failure to observe

On February 25, 2023, Mr Cordy did not apply for bail and was subsequently transferred to the AMC where he was subject to hourly observations for medical reasons.

The coroner said he was able to cover the small observation hatch on his prison cell door which was a matter of public safety.

She said the 34-year-old was last seen alive at 11.40am on February 26, 2023 and was discovered unresponsive by prison staff just before 1pm.

While medical evidence did not allow a finding that a failure to adhere to the hourly observation schedule contributed to Mr Cordy's death, Ms Wilson said a failure to observe those materials in his possession contributed to his death.

"These means were freely available to [certain detainees] and there were no orders or checks of this equipment in place," she said.

Ms Wilson found the unchecked availability of these materials directly contributed to his death.

The coroner said her findings, which would be published in due course, contained recommendations to improve on public safety matters raised in the inquest.

• Support is available for those who may be distressed. Phone Lifeline on 13 11 14, the Suicide Call Back Service on 1300 659 467, or 13YARN on 13 92 76. In an emergency, call 000.

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