Tracy Mackander hoped the coronial inquest into her son Bailey’s death in custody would bring change. Instead, an ABC investigation has revealed a pattern of systemic failures in mental health care across New South Wales prisons, with dozens of inquests finding deficiencies in care and supervision.
Bailey Mackander, a 20-year-old Wiradjuri man, died in 2019 after being placed in an assessment cell at Kariong Correctional Centre. The coroner, Magistrate Elaine Truscott, found a litany of failures contributed to his death, including inadequate mental health assessment, ineffective oversight, and a senior guard who overrode the risk-intervention team’s decision-making.
The ABC examined 249 coronial inquests into deaths in NSW prison custody since 2015. It found that 48 inquests, close to one in five, identified failures in the care or supervision of people with a diagnosed mental illness. In 14 of those cases, the person who died was Indigenous.
The coroner’s recommendations aimed at preventing further deaths included ensuring risk-intervention teams had a psychologist on the panel and that inmates on RITs had access to a support person. Corrective Services NSW refused to support five of the recommendations. Tracy Mackander said she had wanted answers, accountability and change, but got none. “Why do they have these inquests if then nothing is going to change?” she said.
A year later, 47-year-old Aboriginal woman Tammy Shipley died in similar circumstances after nine days alone in a monitored cell. Tracy said the death showed the lessons from Bailey’s case were not learned.
A Corrective Services NSW spokesperson said it carefully considers each recommendation and has strengthened its engagement with the Coroners Court to provide a clearer understanding of the correctional environment. It said specialist teams, including the Risk Intervention Team, use their training and set guidelines to assess and monitor inmates, and it is progressing reforms to improve its response to people in distress. Justice Health, the government agency that employs prison nurses and doctors, said it had improved universal mental health screening, introduced a suicide prevention outreach team, and implemented new training for health staff.
Nerita Waight, head of the peak body representing Indigenous legal services NATSILS, said many families question what inquests achieve. “There is no guarantee that recommendations will be enacted and that deaths will be prevented in future,” she said.
Analysis
Why This Matters
- The high rate of mental illness among prisoners and repeated failures in care highlight a systemic crisis behind prison walls.
- The coronial system’s recommendations being rejected undermines accountability and erodes trust in the process.
- The disproportionate impact on Indigenous prisoners points to deeper inequities in the justice system.
Background
Bailey Mackander was placed in an assessment cell after confessing suicidal thoughts. The coroner found he was isolated, monitored inadequately, and treated punitively. The ABC used AI to analyse coronial findings since 2015, identifying patterns of deficient care in 48 inquests.
Key Perspectives
Tracy Mackander: said the inquest brought no change, no accountability, and that she does not want another mother to stand where she is.
Corrective Services NSW: said it carefully considers recommendations, follows strict legislative frameworks, and is progressing reforms to strengthen identification and response to distress.
Justice Health: said it has improved universal mental health screening, introduced a suicide prevention outreach team, and implemented new training for health staff.
Nerita Waight (NATSILS): said families feel no sense of justice from the coronial process because no one is held responsible and recommendations are not guaranteed to be enacted.
What to Watch
- Whether Corrective Services NSW adopts the five rejected recommendations from Bailey Mackander’s inquest.
- The findings and response to the Tammy Shipley inquest, which may test whether reforms are being implemented.
- Continued pressure from families and Indigenous legal services for systemic change and accountability.
Checked
12 claims in this story checked against 1 source: 12 supported.
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- SupportedTracy Mackander asked, “Why do they have these inquests if then nothing is going to change?”Just In: “"Why do they have these inquests if then nothing is going to change?" Tracy said.”
- SupportedCorrections refused to support recommendations in full in 10 of 32 cases where the response deadline had passed.Just In: “Among the 48 coronial inquests, there were 32 in which the coroner made a recommendation to Corrections NSW and where the six-month deadline for a response had passed. In 10 of those cases, Corrections refused to support the recommendations in full.”
- SupportedThe ABC investigation found a pattern of failures in mental health care across NSW prisons, with dozens of inquests identifying deficiencies in care or supervision.Just In: “An ABC investigation can reveal a prison system that is failing the most vulnerable.”
- SupportedThe ABC examined 249 coronial inquests into deaths in NSW prison custody since 2015.Just In: “The ABC examined 249 coronial inquests into deaths in NSW prison custody since 2015.”
- SupportedOf the 249 inquests, 48 identified failures in care or supervision of people with diagnosed mental illness, close to one in five.Just In: “Of those inquests, 48, or close to one in five, identified failures in the care or supervision of people with a diagnosed mental illness.”
- SupportedBailey Mackander was a 20-year-old Wiradjuri man who died in 2019 after being placed in an assessment cell at Kariong Correctional Centre.Just In: “Then, on November 4, 2019, Bailey called his mother again. He had been moved into an assessment cell after telling a psychologist he was having suicidal thoughts.”
- SupportedThe coroner found failures contributed to Bailey’s death, including inadequate mental-health assessment and a senior guard overriding the RIT’s decision-making.Just In: “The coroner found a litany of failures had contributed to Bailey's death.”
- SupportedCorrective Services refused to support five recommendations aimed at making RIT cells safer, including recommendations about a psychologist and a support person.Just In: “Corrections accepted most of them but refused to support five that were aimed at making RIT cells safer. They would have ensured RIT teams had a psychologist on the panel or at least their advice, that inmates on RITs had access to a support person”
- SupportedTracy said she wanted answers, accountability and change, but did not get any of them.Just In: “"I wanted answers. I wanted accountability, I wanted change," she said. "But I didn’t get any of it."”
- SupportedA year after the recommendations were handed down, 47-year-old Aboriginal woman Tammy Shipley died in a Sydney prison after nine days alone in a monitored RIT cell.Just In: “A year after these recommendations were handed down, 47-year-old Aboriginal woman Tammy Shipley died in a Sydney prison after spending nine days alone in a monitored RIT cell.”
- SupportedTracy said Tammy’s death showed the lessons from Bailey’s case had not been learned.Just In: “Tracy says Tammy's death shows the lessons from Bailey's death weren't learned.”
- SupportedNerita Waight said there is no guarantee recommendations will be enacted or prevent future deaths.Just In: “"There is no guarantee that recommendations will be enacted and that deaths will be prevented in future."”