Coroner finds supervision failures contributed to Justin Cordy's death in Canberra jail

Mr Cordy had been released from the AMC for four days when he was arrested after a high-speed crash in a stolen ute while under the influence of "a considerable amount" of illicit substances. At his arrest he threatened to hurt himself and self-harmed, causing him to bleed, before police Tasered and handcuffed him.

The report said attending police officers failed to inspect his wounds or tell the responding paramedic about the suicide threats or the crash. Body-cam footage captured arresting officers calling the crash a "f---ing tap" and describing the hospital transfer as a "waste of time", and Mr Cordy was sent to Canberra Hospital only after orders from the ACT watch house. At the hospital, body-worn camera captured him telling a triage nurse he had consumed a whole bottle and tried to "neck himself". Ms Wilson called it "unsatisfactory" that neither the paramedic nor the hospital attended to his self-harm wounds.

At the watch house, Mr Cordy had an eight-minute phone call with an Access Mental Health nurse, telling her he had felt "suicidal since he got out of jail" but felt safe from himself at that time and just wanted to talk to someone. The following morning he appeared in the ACT Magistrates Court via audio-visual link and is said to have told an overburdened Legal Aid duty solicitor: "My headspace is just f---ed." Because the Mental Health Court Assessment and Liaison Service did not operate on weekends, he could not undergo a psychological assessment.

Mr Cordy arrived at the AMC with dried blood and gashes on his hands and disclosed his distress during a mental health assessment. The induction nurse found him at risk of self-harm and placed him on hourly observations in the West Wing of the Special Care Centre. Ms Wilson said the individual mental health evaluations by nurses were reasonable based on the information provided to them, and that while his treatment in police custody was "poor treatment" and a matter of public safety, it did not contribute to his death.

The coroner said Mr Cordy was not adequately observed in the AMC and was given access to the materials he needed to die by suicide in his cell. Ms Wilson said he had brought the materials into his cell about 5pm the night before his death, and that they remained in his possession until he was found unresponsive about 1pm on Sunday, February 26. She also said he had been given a shaving razor containing razor blades in his prison welcome pack, and that staff did not detect other missing equipment. “The only finding that can be made with certainty, about the cause of Justin's death, is that had he not had access to [the materials], he could not have [died by suicide],” Ms Wilson said. Photographs taken after his death showed the observation hatch to his cell covered with paper, and observations were recorded on the hour every hour, irrespective of when an observation was actually conducted.

Her recommendations included a mandatory system across the Special Care Centre requiring correctional officers to hand out razors and have detainees sign them back in after use, spot checks on the storage and recording of cleaning equipment, and a cell-searching policy requiring officers to enter cells for visual checks and confiscate unauthorised items. By the time of the coronial hearing, ACT Corrective Services had addressed detainee access to certain areas and made improvements to the observation regime.

"It is my express wish that the failures in Justin's supervision which contributed to his death will not occur again, and no other family will have to suffer the anguish experienced by Justin's family from losing him too soon," Ms Wilson said.

Support is available for those who may be distressed: Lifeline on 13 11 14, 13YARN on 13 92 76, Kids Helpline on 1800 551 800 and Beyond Blue on 1300 224 636.