April 2018


Sick on the inside

By Bronwyn Adcock
Image of David Wotherspoon

David Wotherspoon. Image courtesy of the Wotherspoon family

Our corrective services struggle to cope with the mental health requirements of inmates

Over the final few months of his life, 31-year-old David Wotherspoon, an inmate at Cessnock Correctional Centre in the Hunter Valley region of New South Wales, increasingly believed that prison officers were plotting to kill him: poisoning his food and sending toxic gas into his cell. To protect himself, he barely ate or slept, and armed himself with a “shiv”, a sharpened screwdriver.

In mid March 2013, after months of private torment, he asked to see the mental-health nurse at the prison’s clinic. He was tired and drawn – he’d dropped 7 kilograms – and agitated. “I’m not sick, I know I am not sick,” Wotherspoon told her, continually checking the door, watching for prison officers, worrying he would be overheard. He told her about the plot against him, and about his weapon. “Don’t be afraid, miss. I won’t be using it on you. It’ll be for one of those ones who harms me.” Then he asked for help: he wanted to hand over his shiv and be transferred to the Mental Health Screening Unit (MHSU), a specialist facility at Silverwater Correctional Complex in Sydney, “because they will make me feel better”.

Wotherspoon’s request was probably a brief flash of insight. He had a long history of serious mental illness. He was schizophrenic, and had been in and out of psychiatric hospitals for most of his adulthood. When he was 29, and in an adult prison for the first time, he attempted suicide by cutting his throat with a sharpened toothbrush, and was transferred for treatment at the MHSU.

After his disclosure to the nurse, he was moved to a cell in Cessnock’s Mental Health Unit. This separate wing of the facility, once used for segregation, had recently been converted to house the increasing number of mentally ill inmates pouring into the state’s prisons.

The next day, March 15, Wotherspoon was seen by the unit’s psychiatrist, Dr Christopher Bench, who observed from prison records that Wotherspoon hadn’t been taking his antipsychotic medication for the past four months, but had been using drugs illicitly in prison – dangerous fuel for his illness. Bench assessed that Wotherspoon was in the grip of acute psychosis, and was “decompensating” – a psychiatric term describing a critical mental deterioration. He immediately referred Wotherspoon to the MHSU facility at Silverwater.

Yet when Bench returned to work at Cessnock five days later (his position was only staffed for two days a week) Wotherspoon was still there. Bench wasn’t surprised: “It was not unusual for such urgent cases to have to wait some time until a position was available at the MHSU,” he would later tell the coronial inquiry.

Wotherspoon was waiting inside a “safe cell” – by definition, one with constant CCTV monitoring and no hanging points. Here, in Cessnock’s Mental Health Unit, it was common practice for inmates to be locked down for 23 hours a day, with little company, fresh air or sunlight. Most days, a Risk Intervention Team (a nurse or doctor, and prison staff ) checked on Wotherspoon, and according to their notes his paranoia was unrelenting. He could see needle marks where poison was being injected into his food; some days he took his medication, mostly he didn’t. He told a nurse he used the drug “ice” while inside the unit.

Ten days after he first reached out for help, still waiting, Wotherspoon self-harmed. He’d been expecting a visit from his partner, Corina Mason, but she wasn’t allowed in, having arrived 15 minutes late for visiting hours. Wotherspoon reacted with hysteria, slashing his arm with a shard of glass. For the next five days the lights in his cell were left on permanently.

April arrived. Still Wotherspoon waited, his illness raging. He now thought prison officers were going to abduct him, then kill him. “The screws are trying to knock me, I heard them say it. They are going to put me in the boot of the car and knock me,” he told Mason in a phone call that was recorded, and later transcribed. “I was sick last night, I never took my pills. I knocked on the door grille, put my hands out to say, ‘Knock me, knock me.’”

He was desperate for his transfer. “I’m sick, I need help and they are not moving me. Can you ring up Silverwater and see if I have a bed placement there?” he asked Mason. “I need people to talk to and they just leave us locked in the cell all day … I stayed up all night, I didn’t sleep or take my medication … I need help, bubba …”

On April 4, three weeks after he was referred, a fax arrived at Cessnock saying Wotherspoon had a bed at the MHSU. However, by the time the fax was received and processed, the transport truck had left – and the next one was not due for two days. Wotherspoon was told he would be transferred to the MHSU on April 6.

At 3.06pm on April 5, the day before he was due to leave, Wotherspoon began throwing wads of wet toilet paper at the security camera inside his cell. At 3.14pm, he started again, this time partially covering the lens. A corrective services officer was monitoring the CCTV system, but she didn’t notice what was happening.

Wotherspoon took the shoelaces from his shoes and the cord from his pants. There was a hanging point in his cell – a bolt on the back of the door. He used it to hang himself.

Australia’s prisons are increasingly filled by people with mental illnesses. The last national survey of prisoner health found that nearly half of all prison entrants report being diagnosed with a mental-health disorder. To quantify this, there are 41,000 people in prison in Australia, but the “flow” population – the numbers who spend time in prison or remand over the course of a year – is double that. This means around 40,000 people with mental illness go through Australia’s prison systems annually.

The rates of inmates with more severe and difficult-to-treat conditions – psychotic disorders like schizophrenia – are widely estimated to be 10 to 15 times greater than those found in the general population. However, a recent survey of inmates from four prisons in Western Australia found an even higher incidence: 20 per cent of female inmates had schizophrenia or a related disorder, compared to just 0.35 per cent of women on the outside. The same survey found nearly half of all female prisoners and a quarter of male ones had attempted suicide at some point in their lives.

While mental illness doesn’t discriminate – it can affect anyone, regardless of income or background – incarceration does. The mentally ill who get locked up are usually poor, have insecure housing, struggle with addiction or a cognitive disability, and lack strong family networks to keep them safe. As a group, they face higher rates of convictions for lower-level offences.

“I’m no longer surprised by the number of people with mental illness I see who are in on very petty offences,” says Dr Andrew Ellis, a forensic psychiatrist and fellow at the Royal Australian and New Zealand College of Psychiatrists, who also works in the NSW prison system. “If I had done [what they had], there is no way I would be in jail, because I know a lot of lawyers, and I could post bail, and I’ve got a house I could go to. These people don’t have those kinds of resources.”

Australia’s prisons have become de facto mental-health institutions for our society’s sickest and most vulnerable, and right across the country those who examine and report on the quality of this care are telling a similar, alarming story. “The system is struggling to keep pace with the mental health requirements of the inmates,” says a report from the NSW Inspector of Custodial Services. “With overcrowding and the shortage of psychiatric beds, prisoners with mental health issues are at increased risk of self-harm and even death,” states the Victorian Ombudsman. And, according to the Western Australia Inspector of Custodial Services, there are “inadequate specialist facilities for prisoners with mental impairment and mental health issues”.

Ellis’s task of trying to provide psychiatric care inside a regional NSW prison is an invidious one: he has a waitlist he can never get to the end of, and he’s forced to offer an inferior level of care. “I could not physically see the number of people that would benefit from seeing a psychiatrist,” he says. “And the type of care that I would be able to give would be less than I am able to give in a hospital setting. And many of the people, owing to the severity of their disorder at the time, if they were in the community you would have them admitted into a hospital.”

So do people fall through the cracks? I ask. “It is not really a crack they have to fall through,” he says. “It’s a gaping chasm.”

As with a quarter of all prisoners in Australia, David Wotherspoon was Aboriginal. He grew up in a small coastal town 80 kilometres east of Cessnock. He was one of eight kids, and most of his family still live in the area. They found out that something had happened to David in prison after his sister’s boyfriend overheard on a police scanner that he was being rushed to hospital.

Wotherspoon had been found by two prison officers who were delivering food to the cells. He was resuscitated – with Dr Christopher Bench’s assistance – but once at hospital was found to have irreversible brain damage. He died 10 days later without ever regaining consciousness.

In late August of last year, the coronial findings into Wotherspoon’s death were handed down, and a month later I travelled to his hometown to meet his father. David Wotherspoon Senior, 63, was so thin that the bones of his face were visible under his skin. He told me he’d lost around 24 kilograms over the past few years, due to grief from his son’s death, and stress from the slow unfolding of the coronial process.

Wotherspoon Senior hadn’t visited his son in jail – he’d done his own time and wouldn’t step foot inside the place again – but came to his hospital bedside. He said his son’s unconscious body was handcuffed. “Laying on his deathbed, he was. Two screws next to him. Handcuffed to the bed. Shackled and everything.” Corrective Services NSW wouldn’t answer directly when asked whether this occurred – only confirming that inmates on “medical escort” can be restrained.

His father visited as often as he could – it’s just under an hour’s drive from his home – but the Wotherspoons are not a family of means. The day the doctor wanted to discuss turning off life support, Wotherspoon Senior had no money for petrol. Corrective Services NSW arranged a fuel voucher the next day, and he returned to make the only possible decision.

“I couldn’t go again there once they turned off the machine,” he said. “That was it for me. I couldn’t sit there and hold his hand while he died.”

According to his father, Wotherspoon was a “bit of a wild child”. He left school around Year 6, before he could read or write, and soon started dabbling in drugs. He left home barely into his teens, and ended up doing time in a juvenile prison in Tasmania. His mental-health problems emerged in young adulthood – at 22, he attempted suicide in front of his dad, and spent the next three years in a psychiatric hospital.

He received multiple diagnoses: psychosis, drug-induced psychosis, schizophrenia and antisocial personality disorder. Once he got out of hospital, he was a constant client of community mental-health services. When he was well, he was taking his medication, painting Aboriginal art and talking about opening up a gallery; when he wasn’t, he was using drugs such as heroin and methamphetamines, and ending up back in hospital – another six short-term admissions. Corina Mason, his partner, says he chased drugs to escape “the bad memories he had from growing up” – in particular, exposure to family violence. (His father disputes this account.)

Wotherspoon’s first experience of adult prison, at 29, came just a week after his latest hospital admission. He’d got into an argument over a $50 debt and stabbed a man. He’d been inside for a month when he tried to commit suicide by cutting his throat. While he physically recovered, he remained mentally unwell for his entire nine months in remand, repeatedly reporting that he was hearing voices – including on the day before he attended his court hearing. When he was released on bail he only lasted five months before being charged again, this time over an aggravated break and enter – during which nothing was stolen – and going back to prison.

Without doubt, the man whom the state took into custody – this final time – was severely mentally ill. “What about their duty of care?” asks Wotherspoon Senior. “I want to know why they didn’t do their job. Why didn’t they prevent it?”

The coronial inquest into the death of David Wotherspoon uncovered a litany of errors and oversights. The four thick files, containing thousands of pages of evidence and now sitting in the archives at the NSW State Coroner’s Court, also give a rare insight into what a prison system looks like when it’s struggling to meet the demands of caring for the mentally ill.

Wotherspoon returned to prison in April 2012, with his mental-health status and history of self-harm clearly marked on his file. Considered “at risk”, he was seen approximately once a month by various staff from the state government’s Justice Health and Forensic Mental Health Network, which provides health care inside prisons. Reading through the notes of these meetings is like watching a car crash in slow motion. In May 2012, he has symptoms of paranoia; in June, auditory hallucinations; in August, he refuses his antipsychotic injection, relenting three days later; by November, he’s irritable and consistently refusing his medication; by early 2013, he’s off his medication and denying he’s sick. Wotherspoon then goes seven weeks without an appointment, but when seen again in March admits to injecting buprenorphine – an opiate substitute – and using ice.

Wotherspoon’s mental unspooling inside prison was long and well documented. Yet it wasn’t until he presented himself to the clinic in mid March, with his shiv and rampant paranoia, that a decision was made to escalate his care. According to the coroner, his “mental health deteriorated without sufficiently prompt and active intervention”.

Even once Dr Christopher Bench had identified Wotherspoon’s critical state, it still took three weeks to gain a bed at Silverwater’s MHSU. The consultant psychiatrist who reviewed Wotherspoon’s care for the coroner put this down to the problem of “access block” – in other words, too many mentally ill people and not enough beds. At the time, the MHSU – a facility for male inmates – had 43 beds serving a statewide population of more than 9000 men. (There are still 43 beds at the MHSU, but the male prison population is now more than 12,000).

Deciding who gets these sought-after beds must be a wicked problem indeed. Tucked away in one of the folders of documents supplied to the coronial inquest was the waitlist for beds at the MHSU over the same three weeks when Wotherspoon was waiting. It reads like a rollcall of horror. Each week, 16 other inmates were locked in prison cells around New South Wales, all awaiting transfer, all in states of extreme mental distress. Many were suffering schizophrenia with uncontrolled psychosis, auditory hallucinations and terrifying delusions; one man had cut himself with a razor, and then tried to swallow it; another was so severely depressed he was “actively looking” for ways to commit suicide, and needed to be “watched at all times”.

The inquest uncovered another, more prosaic, reason for the delay in Wotherspoon’s transfer: the necessary paperwork wasn’t filled in until six days after Bench had referred him. The nurse responsible couldn’t recall why it took so long. However, the enormous workload faced by the prison’s health staff was evident. The two mental-health nurses responsible for the 12 critically ill inmates in the Mental Health Unit at Cessnock were frequently called away to deal with sick inmates among the prison’s mainstream population of 800. Bench was seeing 12 patients, and reviewing hundreds of files every shift – a caseload he described as “intensive”.

Inadequate staffing also played a role in the critical oversight made in the CCTV monitoring room the afternoon of Wotherspoon’s suicide – as he began throwing wads of toilet paper at his cell camera. The corrective services officer who missed this was on her own, on her first ever shift in the monitoring room. She was responsible for keeping track of all the cells in the Mental Health Unit – displayed as 64 separate images – plus other camera feeds from around the jail, while also taking phone calls and answering cell call-alarms from inmates. Her training was so minimal that a couple of hours earlier she’d been unable to activate the electronic locks to allow another officer finishing his shift to leave. (Corrective Services NSW has recently changed policies and procedures around the monitoring room.)

Of all the cracks Wotherspoon fell through, the final and ultimately fatal one was the presence of a hanging point inside his “safe cell”. In the immediate aftermath of his death, the Corrective Services Investigations Unit discovered that all the cells in the Mental Health Unit had the same hanging point on the back of the door. (The doors have since been replaced.)

Such an oversight appears extraordinary – when Wotherspoon hanged himself, it was 22 years since the Royal Commission into Aboriginal Deaths in Custody drew attention to the need to screen hanging points in cells. However, it’s an oversight that continues to occur across the country. A recent report from the Australian Institute of Criminology, examining all deaths in custody between 1999 and 2013, found that the coroners involved made 33 separate recommendations about reducing hanging points, reminding prison systems – again and again – about the need to ensure compliance with “safe cell” principles. Last year, while investigating two deaths by hanging, the Northern Territory coroner said it “beggars belief that a prison designed and constructed in the 21st century has such classic hanging points with no mitigation of that risk”.

The coroner investigating Wotherspoon’s death, Magistrate Michael Barnes, did not assign blame to any of the individuals who tried to care for him in his final days. The coroner also accepted the opinion of the psychiatrist who reviewed the case, Associate Professor Michael Robertson, that there “appears to have been laudable efforts to manage the situation in an imperfect setting”.

This “imperfect setting” was not examined by the coroner, who focused on Wotherspoon’s death alone. But Dr Christopher Bench, the psychiatrist who worked in the Mental Health Unit, gave a submission to the inquest about his view of the conditions for mentally ill inmates in the unit.

Because of the limited number of Corrective Services Officers available to supervise patients housed in the Mental Health Unit, patients were often confined to their cells all day and had minimal interaction with other people. The cells in the Mental Health Unit had little light or fresh air … deprivation, isolation, lack of human contact and lack of external stimulation can potentially increase symptoms of acutely psychotic patients.

In the months after Wotherspoon’s death, Bench and one of the mental-health nurses resigned. Bench said he left because he “believed the conditions in the Mental Health Unit were not suitable for the practice of good psychiatry”. The unit has since been closed down.

In March 2013, at the same time that David Wotherspoon was deteriorating inside his prison cell, another young Aboriginal man was languishing in custody on the other side of the continent. Jayden Bennell was just 20 and, like Wotherspoon, had entered prison as a person clearly identified with chronic mental illness. Initially, he had regular sessions with a psychiatrist, but then, largely due to a shortage of psychiatrists and a constant re-prioritising of cases perceived as more serious, he went seven months without an appointment, before he hanged himself inside a storage room at Western Australia’s Casuarina Prison.

Eight months later, also in Western Australia, Barry Stuart, a 49-year-old prisoner, committed suicide in Hakea Prison while waiting for a new prescription. Stuart had a history of depression, drug-induced psychosis and attempts at self-harm, and had been taking a prescribed antipsychotic medication. However, there was uncertainty about whether this was the correct medication – he liked it because it helped him sleep – and he needed a psychiatric review to determine if he should continue. But the chronic shortage of psychiatrists meant he kept missing out on his appointment. It was two weeks after he stopped taking the medication, because his last script had run out, that Stuart took his life.

The inquests into these two deaths were held last year. Both heard similar evidence about the paucity of psychiatric services within the prison system – a consultant psychiatrist, Dr Adam Brett, described it as “underfunded and under resourced”. In an environment of scarcity, prisoners with mental-health problems perceived as less serious, like Bennell and Stuart, can simply miss out.

By the time of the inquest into Bennell’s death, access to psychiatric resources at Casuarina Prison had doubled from one to two days a week. When asked about the impact of this increase, Brett said they were still “just managing the tip of the iceberg”. He said that in the United Kingdom approximately 10 per cent of the mental-health budget is put into forensic mental health, whereas in Western Australia it’s more like 1 per cent.

The coroner investigating these deaths, Sarah Linton, issued the same recommendation for both: that the WA Department of Corrective Services should invest significantly more resources in giving prisoners regular access to psychiatrists, and adopt a more holistic approach to mental-health care.

Coroners’ courts and the media continue to document cases of desperately sick inmates dying in custody. In December, Senator Pat Dodson, who was a commissioner on the Royal Commission into Aboriginal Deaths in Custody, called on all state governments to legislate a “duty of care” to prisoners. This followed a report in Sydney’s Sun-Herald about the death in custody in mid 2017 of an Aboriginal man who, like Wotherspoon, spent his final days shackled while brain dead.

Eric Whittaker, a father of five children, homeless and with drug abuse problems, was arrested in Sydney last June for several offences, including allegedly failing to appear before court. NSW Corrective Services commissioner Peter Severin told The Sun-Herald that “bail was refused, most probably because of his inability to have a place of residence”. On Friday, June 30, Whittaker was transferred to Parklea jail in Sydney’s north-west. “On arrival, he was automatically classified as a maximum-security inmate because Parklea does not conduct security assessments on weekends,” The Sun-Herald reported.

About 8am on Sunday, July 2, corrections officers realised something was wrong, they said.

Doctors were later told Mr Whittaker had been in an isolation cell, incontinent, agitated and handcuffed, The Sun-Herald understands.

“He had trashed his cell,” Mr Severin said.

“He was incoherent, he was quite uncontrollable, so that’s when medical intervention immediately commences …”

He was rushed in an ambulance to Blacktown Hospital at 10.47am, bound hand and foot, under the supervision of two guards. Combative on arrival, his condition then deteriorated further, The Sun-Herald understands.

It’s little wonder he was distressed. Brain scans revealed that Whittaker had had an aneurysm. He died in hospital two days later.

Whittaker’s family released a photo of him lying in his hospital bed, brain dead and shackled at the ankles.

Whittaker was reportedly the cousin of David Dungay Junior, a 26-year-old who died in a state of great distress while inside the mental-health unit at Sydney’s Long Bay jail in 2015. Dungay was in the unit after being diagnosed with chronic schizophrenia with acute psychosis. According to reports, he got into a confrontation with corrective services staff because he refused to follow an order to stop eating biscuits. He was restrained facedown on a mattress and injected with a tranquilliser, complaining he couldn’t breathe, shortly before stopping breathing altogether. He was due to be released on parole in three weeks.

In late February, an inquest began at the NSW State Coroner’s Court into the death in custody of Junior Fenika (Togatuki). The 23-year-old, who’d developed serious mental illness – including schizophrenia – while in custody, was being held in an isolation cell in Goulburn’s “supermax” prison. His sentence had finished a month earlier and he was waiting to be deported to New Zealand (he’d left there at the age of four). Fenika’s mental health was reportedly deteriorating when he took his life. His family is being represented by the National Justice Project, a Sydney-based, human rights–focused law firm. According to their principal solicitor, George Newhouse, “Junior was alone and desperate and one night cut himself with a razor blade. But the family are looking for answers to some very tough questions. How did he get the blade? Did his cries for help go unanswered? And are our prisons filled with mentally ill people who have access to shockingly limited health services?”

Growing numbers of mentally ill people entering prison is a trend right across the Western world. The United States prison system now has the ignominious distinction of being the largest psychiatric institution in the country: more mentally ill people end up in prisons than in hospital beds.

The roots of this problem lie outside the prison walls: a chronic lack of funding of mental-health services in the community, a shortage of long-term mental-health beds, and a lack of access to substance abuse treatments. Criminal justice systems that take the “tough on crime” approach (popular across many Australian jurisdictions over the past decade) also help funnel the mentally ill into prison, with this group often ending up in jail for relatively minor offences.

“This is not about catching the Mr Bigs of drug importation or gun importation,” says criminologist Professor Eileen Baldry. “This is largely about summary offences, drug offences, minor violence, stealing, and the more we use the criminal justice system to address those behaviours then the more that group will end up in prison. And that’s what they have seen in the US and we are heading down that road, and we should not.”

For Baldry, the important question is not how we treat these people in prison, but why we have them there in the first place. “The fundamental point is that most of them should not be in prison. The fundamental point is that if we strengthened our community mental-health services, if we strengthened our support for disadvantaged and poor families, to support their kids as well as themselves when they are being assaulted by a range of things, including mental-health disorder, they would not go to prison and they should not have to go to prison,” she says.

Diversionary programs that keep offenders with mental illness out of prison have been in place for decades – and have been shown to reduce the incidence of offending. However, across Australia their scale is relatively small. In New South Wales, the Justice Health and Forensic Mental Health Network says it “strongly supports the diversion of adults and young people with identified mental illness from custody”, and that between 2016 and 2017 roughly 3000 adults and young people with mental illness were diverted to the community.

Last year at Cessnock Correctional Centre, a steady stream of utes driven by men wearing high-vis entered through a back gate into an area piled with construction material. In the distance, heavy machines cleared vast swathes of land – the site of a new “rapid-build” prison, one of two in New South Wales. In late January, barely a year after construction began, the facility was officially opened – ready for 400 inmates to be housed in dormitory-style pods. The state is currently spending $3.8 billion building a dozen new prison facilities, an extra 7000 beds to cope with the rapidly expanding prison population.

In New South Wales, between 2013 and 2016, the prison population grew by 26 per cent, but the funding allocation for the Justice Health and Forensic Mental Health Network – which is expected to deliver services to the growing number of mentally ill inmates – hardly shifted.

Justice Health says it has dealt with this by developing a new model of care: specialist mental-health services are prioritised for the severely mentally ill, while the less seriously ill are seen by a GP or nurse. It has also expanded the use of “telehealth” services and 24/7 hotlines.

However, those who work in the system say serious investment is needed. “As a society we have invested much more in bricks and mortar of the prisons’ walls and the barbed wire and not enough in the human resources in terms of psychiatric care for this section of prisoners,” says psychiatrist Dr Andrew Ellis, who works one day a week inside a NSW prison.

A recent report from the NSW Inspector of Custodial Services found that the average wait time for an inmate to see a psychiatrist is 42 days and to see a mental-health nurse is 27 days.

“This has reached the limit of what is tolerable,” Ellis says. He believes the care provided is “good enough” for some within the prison system, although not ideal by any means, and certainly wouldn’t be equivalent to what they get in the community. Worse, however, is that “there is a number of people that we don’t even get to see”.

Increasingly, this leaves corrective services officers on the frontline of mental-health care. “So we become a nurse, we become a welfare officer, we become a teacher, and in all honesty our training is extremely limited to be able to deal with people with mental-health issues,” says Nicole Jess, a corrective services officer and chair of the prison officers’ union.

Jess works inside Sydney’s Silverwater Women’s Correctional Centre, where she says mentally ill women frequently wait weeks for a specialist bed. The beds exist, but “just not enough, the demand is never met”.

In the meantime, the compromise is to place them in the prison’s induction unit – the part of the prison for new arrivals. It’s the best of a bad choice: staff ratios are higher here, so there’s a little more care, but it’s a potentially volatile area. “This is where inmates who first come into custody go,” Jess explains. “So you’ve got new people who’ve come in off the street, they’re withdrawing, they’ve been taken away from their kids, taken away from family, and they are not happy, and they have to share with mental-health inmates.”

Housing severely mentally ill inmates in the mainstream prison population – even in an induction area – makes them acutely vulnerable. Prison is a survival-of-the-fittest environment. “[Other prisoners] can assault them and they might complain to the guards, but the guards might think they are paranoid,” says Ellis. “Or they can have their medication stolen … They’re often wound up for entertainment by other prisoners.”

Jess regularly deals with women in the mainstream prison population who are severely mentally distressed, from the acutely psychotic to the behaviourally disturbed – women who can’t feed or bathe themselves, or who are throwing faeces or blood. She does her best with what she has: “We sometimes give them crayons, but then we’ve had inmates who put the crayons in their eyes or they’ve eaten the crayon.” Often her only tool is placing them in segregation.

“We are locking them in, on a regular basis,” Jess says. “For other people’s safety and their own safety.” She acknowledges that putting a prisoner in isolation can have an adverse effect, but if the priority is to get a prisoner to calm down, sometimes “the only way you can do that is lock them down”.

A recent investigation into Australian prisons by Human Rights Watch found widespread evidence of people with mental illness being placed in prolonged solitary confinement. These findings support earlier work, from the Human Rights Law Centre, that says there is “substantial” evidence across Australia that mentally ill inmates are often “managed” by segregation.

This is despite a wealth of evidence going back decades showing the dangers of this practice. As Ellis points out, “for someone who already has difficulty appreciating reality as part of their mental illness – they might be hallucinating, hearing people talking, and it’s usually unpleasant content – placing them in solitary confinement tends to worsen their symptoms and their outcomes”.

According to a 2014 investigation into deaths in custody by the Victorian Ombudsman: “My investigation identified a number of cases where prisoners held in solitary confinement for up to 23 hours per day had attempted suicide or self-harm.”

As a 30-year veteran of the prison system, Jess well understands the potential harm of her actions. “It just exacerbates your stress levels, when you see that what you are trying to do could have an adverse effect on them,” she says.

According to Jess, it’s hard to escape a sense of futility when “we are becoming these warehouses and not actually treating the person”. Inmates with mental illness, particularly in combination with substance abuse, have high rates of recidivism. “A lot of the time it’s just a revolving door – they go out into the community, and there’s a lack of resources out in the community, and then they come back in … and it’s just not stopping, it’s getting worse.”

From a psychiatric viewpoint, incarceration is fundamentally incompatible with effective mental-health treatment. “You can’t give people adequate mental-health treatment in custody, because custody is about detention and punishment, it is not about treatment and care,” says Dr Ness McVie, a forensic psychiatrist who has worked in both the Queensland and NSW systems.

She says simply being placed under observation, most of it electronic, in a cell on your own, with no therapeutic interventions but with access to illicit drugs “is not mental-health treatment, it is just not … And most of these guys in jail end up like David Wotherspoon, treated by mental-health services who are trying to do the best they can, but who don’t have many options.”

There was a curious note in David Wotherspoon’s lengthy prison file. It concerned an incident in late 2012, about six months before he died, when he was mistakenly told he was about to be paroled. What was interesting was Wotherspoon’s reaction: he was anxious about getting released, and relieved when told the next day it was all a mistake.

I asked Corina Mason, his partner, about this, and she said it sounded about right. David liked institutions, she told me; juvenile prison was where he discovered his aptitude for art, and he always turned to hospital for help when he needed it. This prison sentence had come at a time when he was mentally unwell, using drugs again, about to lose the apartment he was living in, having problems with his family. It might have seemed like a saving grace.

Even when his mind was tormented by illness, it seems David always knew enough to know when he needed help and care. His mistake was to think this could be found in prison.

For support, call Lifeline 13 11 14.

Bronwyn Adcock

Bronwyn Adcock is a freelance journalist whose work has appeared in The Griffith Review and The Saturday Paper and on the ABC. She is the author of Currowan.

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Rethinking the republic

A change in our head of state won’t change everything, and other lessons for the next push

Tim Winton’s ‘The Shepherd’s Hut’

One of Australia’s most acclaimed novelists offers a painful and beautiful story of redemption

The republic is an Aboriginal issue

Recognition must be at the heart of constitutional reform

Zadie Smith’s ‘Feel Free’

In this collection of essays, Smith shines when she’s addressing the personal

More in The Monthly Essays

Image of red-paint hands on Yuendumu Police Station

The death of Kumanjayi Walker

On the shooting in Yuendumu and the trial of Northern Territory policeman Zachary Rolfe

Image of Prime Minister Scott Morrison during Question Time, 2021

Morrison’s power without purpose

As prime minister, Scott Morrison has offered neither competence nor vision

Portrait of Zoe Daniel

Independents and the balance of power

The federal election may hinge on a new crossbench of professional women in wealthy inner-city seats and a rural revolt against the Nationals

Photo of Marind community members sharing dreams of being eaten by oil palm

The psychic terror wrought by palm-oil production

How oil-palm plantations have uprooted the lives and dreams of a Papuan community

Online exclusives

Image of US President Joe Biden meeting virtually with Chinese President Xi Jinping from the Roosevelt Room of the White House, November 15, 2021. Image © Susan Walsh / AP Photo

The avoidable war

Kevin Rudd on China, the US and the forces of history

Composite image of Prime Minister Scott Morrison and Opposition Leader Anthony Albanese speaking during the first leaders’ debate on April 20, 2022. Image © Jason Edwards / AAP Images

Election special: Who should you vote for?

Undecided about who to vote for in the upcoming federal election? Take our quiz to find out your least-worst option!

Image of the Stone of Remembrance at the Australian War Memorial, Canberra. Image © Lukas Coch / AAP Images

Remembrance or forgetting?

The Australian War Memorial and the Great Australian Silence

Image of Opposition Leader Anthony Albanese, Labor MP Emma McBride and shadow housing minister Jason Clare after meeting with young renter Lydia Pulley during a visit to her home in Gosford on May 3, 2022. Image © Lukas Coch / AAP Images

Property damage

What will it take for Australia to fix the affordable housing crisis?