Psychiatrists have warned that cells intended to prevent self-harm can worsen mental illness among vulnerable prisoners held alone under camera surveillance in New South Wales. An ABC investigation highlights Daniel Turnbull’s death from excessive water consumption while awaiting psychiatric review at Bathurst Correctional Centre.
Turnbull, 35, who lived with schizophrenia, died in October 2022 after drinking about 40 litres of water on his final day. Deputy State Coroner Erin Kennedy found the resulting hyponatraemia, dangerously low sodium levels that caused his brain to swell, could have been prevented with informed, close monitoring.
Prisons use closely monitored isolation cells to protect inmates considered at risk of suicide or self-harm, removing or minimising hanging points. But psychiatrists told the ABC that isolation and sensory deprivation pose risks to prisoners’ mental health, while camera supervision leaves their care dependent on guards without clinical training.
A mental health nurse recommended Turnbull’s placement after he reported hearing voices and fearing other inmates, and his records showed missed antipsychotic medication. He was due to see a psychiatrist three days later. A guard monitored cameras covering 14 cells, and Turnbull had spent more than 50 hours isolated when he collapsed.
His excessive drinking was a condition known as polydipsia, which can occur in people with schizophrenia. Forensic psychiatrist Danny O’Sullivan told the inquest that untreated psychosis and confinement with few distractions could contribute to its development.
The ABC identified three prisoners with schizophrenia who died from polydipsia in less than two years. They included Tammy Shipley, an Aboriginal woman who died at Silverwater women’s prison in December 2022 after spending 10 nights alone in a safe cell. Forensic psychiatrist Olav Nielssen told her inquest that isolation likely contributed to her excessive drinking.
Kerri Eagle, a forensic psychiatrist and Justice Health clinical director speaking in her private capacity, said isolation could cause panic, cognitive impairment, paranoia and delirium. She argued that prisoners with major mental illness needed treatment in a therapeutic environment, and that Justice Health should have sole responsibility for assessing and managing at-risk inmates.
“It is not appropriate for Corrective Services to be managing those health conditions because their goals are security and law enforcement,” she told the ABC.
Corrective Services said it operates within strict legislative and regulatory frameworks and delivers mental health care jointly with Justice Health through multidisciplinary teams. Justice Health said it was committed to working with the prison agency on appropriate placements for mentally unwell people in custody.
In Turnbull’s case, a guard noticed him on the floor 13 minutes after his collapse. An ambulance was called after a nurse arrived, when he was face down, blue and had vomit pooling from his mouth. Intensive care specialist Michael O’Leary told the inquest that the collapse should have prompted immediate medical attention, although intervention was probably already too late.
Kennedy found that those monitoring Turnbull would have needed to know excessive drinking could be dangerous. Corrective Services said it had updated policies to identify excessive water intake as a risk and made changes to improve responses to distress and collaboration with health services.
Analysis
Why This Matters
- Camera surveillance can reveal a prisoner's behaviour without ensuring that those watching recognise a medical emergency. Turnbull’s case exposes the importance of clinical knowledge alongside observation.
- The dispute concerns who should direct care for prisoners with serious mental illness, and whether isolation intended to protect them instead increases their vulnerability.
Background
Prison authorities have responsibilities for both security and the welfare of people in custody. Clinical care and custodial supervision serve different functions, making coordination particularly important when mental illness affects a person’s behaviour or ability to seek help.
Polydipsia involves excessive water consumption. In Turnbull’s case, the resulting fall in sodium caused brain swelling, illustrating how an apparently ordinary activity can become a medical emergency.
Key Perspectives
Kerri Eagle: Says isolation is not a therapeutic response to major mental illness and wants Justice Health to control assessment and management of at-risk prisoners.
Corrective Services NSW: Says it manages prisoners within legislative safeguards, provides care jointly with Justice Health and has strengthened policies for identifying distress and excessive water intake.
Justice Health: Says it works with Corrective Services to support appropriate placement of mentally unwell people in custody.
What to Watch
- Whether updated policies are accompanied by training that helps monitoring officers recognise excessive water consumption and other signs of deterioration.
- Whether placement and treatment arrangements give vulnerable prisoners timely psychiatric care and meaningful human contact.
- Whether responsibility for clinical risk assessment changes in response to the concerns raised by psychiatrists.
Checked
11 claims in this story checked against 1 source: 11 supported.
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- SupportedPsychiatrists questioned NSW prison isolation cells after deaths among prisoners under monitoring.Just In: “The ABC can reveal Daniel was one of several NSW prisoners to die in recent years after being put in a monitored isolation cell, often due to fears for their own safety. It has experts sounding the alarm about the risks of these cells”
- SupportedCorrective Services said it had changed its response to prisoners in distress.Just In: “A spokesperson said CSNSW had made changes to better identify and respond to people in distress and ensure collaboration between custodial staff and health services.”
- SupportedKerri Eagle called for Justice Health to have sole responsibility for assessing and managing at-risk inmates.Just In: “She wants the assessment and management of at-risk inmates brought under the sole remit of Justice Health, an arm of the New South Wales Health department.”
- SupportedPsychiatrists warned that isolation cells can harm vulnerable prisoners’ mental health and leave their care to guards with little or no mental-health training.Just In: “It has experts sounding the alarm about the risks of these cells, where isolation can have a catastrophic impact on health and where vulnerable prisoners are left to the supervision of guards with little to no mental health training.”
- SupportedDaniel Turnbull, 35, died in October 2022 after drinking about 40 litres of water on his final day.Just In: “Daniel was 35 years old when he died at Bathurst Correctional Centre in October 2022. [...] On his third day, it was about 40 litres”
- SupportedDeputy State Coroner Erin Kennedy found Turnbull’s hyponatraemia could have been prevented with close monitoring, if monitors knew excessive water intake could be dangerous.Just In: “Deputy State Coroner Erin Kennedy found Daniel's hyponatraemia could have been prevented if he had been closely monitored, but those monitoring him would need to have known excessive water intake can be dangerous.”
- SupportedA nurse recommended placing Turnbull in a camera cell after he reported hearing voices and fearing other inmates; his records showed missed antipsychotic doses.Just In: “the nurse knew she wanted him kept safe until she could get him in to see a psychiatrist in three days' time. So she recommended he be sent to a camera cell [...] she'd missed a number of doses of his antipsychotic meds”
- SupportedTurnbull had been isolated for more than 50 hours when he collapsed, and a guard monitoring CCTV of 14 cells spotted him on the floor 13 minutes later.Just In: “he would be watched by a security guard who monitored the CCTV of all 14 cells. [...] By the time Daniel collapsed he had been in the cell for more than 50 hours. [...] A guard in the monitor room spotted him on the floor 13 minutes later”
- SupportedThe ABC identified three prisoners with schizophrenia who died from polydipsia in less than two years.Just In: “The ABC has previously revealed Daniel was one of three prisoners with schizophrenia to die from polydipsia in less than two years.”
- SupportedKerri Eagle said, “It is not appropriate for Corrective Services to be managing those health conditions because their goals are security and law enforcement.”Just In: “"It is not appropriate for Corrective Services to be managing those health conditions because their goals are security and law enforcement," she said.”
- SupportedCorrective Services said it updated policies to identify excessive water intake as a risk and made changes to improve responses to distress and collaboration with health services.Just In: “A spokesperson said CSNSW had made changes to better identify and respond to people in distress and ensure collaboration between custodial staff and health services. This included updating its policies to identify excessive water intake as a risk”
