TRANSCRIPT
Darkinjung man Timothy Garner died while he was being held at Sydney's Silverwater Centre on July the 7th, 2018.
In the week before he died, a psychiatrist recommended the 30-year-old father of two, who had been diagnosed with bipolar disorder and schizophrenia, be transferred to a mental health facility.
But five days before he took his own life in his cell, he was removed from a waitlist for a mental health bed after his condition was deemed to have improved.
Speaking outside a coronial inquest into his death, his mother Michelle Garner said her son had been "let down by the system".
"He had so much life left to live. Tim's death could have been avoided if he'd received the appropriate healthcare, he'd still be with us today. I don't what happened to Tim swept under the carpet, I don't want this to happen to anyone else."
Mr Garner was on remand after being charged with robbery and possession of a prohibited drug three months earlier.
The inquest, which heard evidence in 2023, focused on the decision made by Silverwater's risk-intervention team, or RIT, to clear his mental health assessment.
Delivering his findings, Deputy State Coroner Derek Lee said it would have been more appropriate for Mr Garner to remain under the team's management, and the time taken for Mr Garner to be reviewed by psychiatrists in May and June of 2018 did not conform with defined timeframes.
Mr Lee found in the five-day period before his death, Mr Garner was not reviewed adequately - that he was, in fact, not reviewed at all.
The coroner also noted a failure by prison staff to communicate with Mr Garner's family, as his mother described outside the court.
"The last time I saw Tim alive, I told prison staff he needed to see a doctor, he needed to be medicated, but I wasn't kept informed about my son's condition. Me and my partner kept calling Silverwater begging to help him, but no-one ever returned our calls."
The findings of the inquest into Timothy Garner's death comes after the release of statistics this week which show Indigenous deaths in police custody nationwide have doubled since 2007.
Families and and legal advocates are demanding change, criticising a failure by Australian state and federal governments to put into action the recommendations of the landmark 1991 Royal Commission into Indigenous deaths in custody.
Ashleigh Buckett is an Associate Legal Director at the National Justice Project, which has represented the families of other Indigenous people who have died in custody.
She says with 500 deaths in custody since 1991, but only a handful of prosecutions, the failure to implement the Commission's findings may need to go to the international legal stage.
"For over 30 years the Australian government has had the Royal Commission findings, and it's had the benefit of findings from further inquests into deaths in custody. It really does have the guidelines and the recommendations it needs to create change - I think the question is now, do they have the will?"
The original recommendations included removing hanging points from the cells of inmates with a history of self-harm, for which Coroner Lee has now given a deadline of until the end of 2024 in New South Wales.
Emma Parker, Coronial and Trial Advocate at the Aboriginal Legal Service, which represented Mr Garner's mother at the inquest, say they also want to see more humane cells for inmates on RIT management programs.
"The Darcy cells for those on the RIT team that Tim was placed in were very limited. Effectively concrete, mattress on the ground, and unfortunately not much else, and (when) you've got people struggling with their mental health, obviously diversionary tactics are important for their therapeutic treatment."
The inquest also raised concerns about the level of mental health training received by those who work in corrective services on risk intervention teams, with the coroner recognising the need for refresher training.
The Productivity Commission figures released show Aboriginal and Torres Strait Islander People were also over-represented in deaths from suicide and causes of death including drug overdoses, injury or homicide.
Paying tribute to her son outside the court, Michelle Garner said better mental health training and support in prisons is a matter of common sense for all prisoners.
"Prisons are full of people with mental illnesses, they need to access psychiatrists, they need to be treated. There needs to be a much better support for prisoners at risk of suicide or self-harm."
If you or someone you know needs crisis support, contact Lifeline on 13 11 14, the Suicide Call Back Service on 1300 659 467 and Kids Helpline on 1800 55 1800 (for young people aged up to 25). More information and support with mental health is available at beyondblue.org.au and on 1300 22 4636.
Embrace Multicultural Mental Health supports people from culturally and linguistically diverse backgrounds.
For culturally appropriate Indigenous support call 13 YARN, a 24 hour national telephone helpline on 13 92 76 which provides support across a range of issues including mental health.
