At the time of his death Junior Fenika was receiving anti-psychotic treatments. (Supplied: Sharon Togatuki)
A coroner has found that the suicide of a prisoner in Goulburn’s Supermax jail could have been prevented if officers had checked on him properly.
Junior Fenika, 24, took his own life while being held in September 2015, a month after completing his seven-year sentence.
He was awaiting deportation to New Zealand because his visa had been cancelled on the grounds of his character.
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On the night he died he twice used the prison intercom to tell a guard he had harmed himself.
The prison officer did not understand what Mr Fenika said, but asked two other guards to check on him.
“Neither was in a hurry to attend Unit Seven to check on Junior and they did not leave the meal room for at least 15 minutes to do so,” deputy state coroner Teresa O’Sullivan found.
“The first round of the National Rugby League finals was on that night and the game was likely to have been concluding at about the time of [the officer’s] call.”
Neither guard said they could remember watching the football and they had not been told that Mr Fenika’s call could have been an emergency.
When the guards did leave the meal room they walked to Mr Fenika’s unit and looked, listened and smelled at cell doors but did not approach the door of Fenika’s cell.
The Fenika family were very emotional after the findings were handed down. (ABC News: Leah Sellers-Fay)
Ms O’Sullivan has censured the two guards for not, at that point, using the intercom to speak to Mr Fenika.
“It was a clear failure by the two officers to take an obvious step and is deserving of censure,” she said.
“It is likely that if the call had been made that Junior would have told them he had [harmed himself] and they could then have taken immediate action.”
She has also criticised the first officer who took the call for not calling Mr Fenika back to clarify what was wrong.
“It is likely that had they discovered that Junior had [harmed himself], the night senior would have been informed, an ambulance called and Junior would not have died.”
Instead, no-one opened the door to Mr Fenika’s cell until 8:30 the next morning, even though four prison guards walked past, stepping in a mix of blood and water seeping out of Mr Fenika’s cell.
Prisoner had lived in Sydney since he was six
Ms O’Sullivan has made 10 recommendations to Corrective Services New South Wales about Goulburn Supermax, including improving the prison’s intercom system and making changes to their night watch procedures.
She also recommended that Corrective Services formally consult with Justice Health as to whether inmates at Goulburn should have access to sharp implements like razors if they have recently engaged in or threatened self-harm or been supervised by a risk intervention team (RIT).
Mr Fenika had been placed on a RIT in July 2015 and saw a psychiatrist in August 2015 who noted “an increase in psychotic depressive symptomatology”.
Corrective Services and Justice Health observed that Mr Fenika became more stressed after being told that after his sentence expired he would await deportation at Goulburn rather than being transferred to Villawood Immigration Detention Centre.
Outside court Mr Fenika’s sister, Sharon Togatuki, said the family was pleased with the recommendations but still traumatised about what happened.
“He was a good kid, he was just with the wrong crowd but he was brought up by a Christian family,” she said.
Mr Fenika moved to Sydney with his family when he was six, but never took up Australia citizenship.
He began to fall foul of the law when he was 13 and was imprisoned for a range of offences from the age of 18.
Two psychiatrists told the inquest they were of the opinion that Mr Fenika was suffering from schizophrenia at the time of his death.
Ms O’Sullivan recommended that the State Government review whether or not there were enough beds available for the treatment of mentally ill prisoners, that Corrective Services be given security support to transfer prisoners from Goulburn to Silverwater gaol for mental health treatment and that policies about keeping inmates in isolation be amended.