A former royal commissioner is dismayed at the “unconscionable” treatment of a mentally ill man who was deliberately denied water to his cell in the days before he died from a treatable illness that prison health staff inexplicably missed.
The treatment of Simon Cartwright, a man diagnosed with schizophrenia and bipolar disorder, in Sydney’s Silverwater prison has drawn widespread condemnation from mental health experts and advocates.
Guards at Silverwater deliberately turned the water to Cartwright’s cell off, initially due to a flooded cell, but then later as a tool of coercion and punishment in 2021. Guards joked that his repeated pleas for it to be turned back on were “entertaining”.
Cartwright was then left unobserved for long periods, despite being locked in cells with 24/7 video surveillance at Silverwater’s remand centre. Staff missed him collapsing repeatedly, including three times on the day before his death.
He died of septic shock from an untreated gastric ulcer missed by prison health staff during an intake screening. Prison health staff failed to check their own prior records, which showed a history of gastric ulcers. This meant a “gastric ulcer was not suspected or considered”.
A coronial inquest heard evidence from one expert who said it would have been obvious to a layperson that Cartwright was mentally unwell and required treatment.
The coroner also found prison guards required more mental health training and “had a lack of awareness of the nature and severity of Simon’s mental health issues”. They were not made aware of the reason he was in the observation cells. This was unfair on the guards, the inquest found.
Prescription medication would have saved him if administered for five days prior to his death, a coroner found.
The failures all happened while the 41-year-old waited for a place in a secure mental health hospital, which he should have received 16 days before his death, but did not due to chronic under-resourcing of the system.
Bernadette McSherry, an emeritus professor and expert in mental health law, helped lead a royal commission into the Victorian mental health system in 2021.
She said there was a lack of secure mental health beds across Australia and also a pressing need to provide better care and treatment before people came into contact with the justice system.
“I’m dismayed to learn of the circumstances of Mr Cartwright’s death,” she said.
“It is unconscionable … for people with severe mental ill health to be denied their right to treatment on an equal basis with others.”
Patrick McGorry, a former Australian of the year and leading mental health expert, described Cartwright’s treatment as a “disgrace” that showed again how those with mental illness are ending up in prisons due to a lack of social care and mental health treatment in the community.
“It shows how jails are not safe places for the mentally ill,” he said.
“This is not a safe place for anyone, but it’s particularly not safe for people with mental illnesses.”
Community Mental Health Australia (CMHA) described the case as “a profound human rights violation” and People With Disability Australia (PWDA) said the “withholding of basic human needs like water” constitutes “government-regulated violence”.
The strategic partnerships manager of CMHA, Francis O’Neill, said he was “very deeply saddened and not in the least surprised” to learn of the circumstances of Cartwright’s death.
He said that, since the process of de-institutionalisation, the mental health system had been so neglected that vulnerable people were getting “funnelled into emergency departments and jails, places where they shouldn’t be”.
“Simon’s death highlights the systemic abuse faced by individuals with mental illness,” he said. “If you have a psycho-social disability, you’re a non-citizen, if you have a severe psycho-social disability, you’re in the system.
“It’s a failure of policy. But it’s not just that. It’s a profound human rights violation.”
An analysis of unmet need for psychosocial supports, prepared for the federal government, showed that 230,500 individuals aged 12 to 64 with severe mental illness did not receive essential supports in 2022-23.
The PWDA’s deputy chief executive, Megan Spindler-Smith, said her first reaction upon reading of Cartwright’s case was: “not again.”
She said the use of restrictive practices, like the denial of water, could harm people with disability and was inexcusable.
“This can’t keep happening, regardless of the setting,” she said.
Justice Health said it acknowledged the pain caused by Cartwright’s loss and extended its sincere condolences to his family.
“We are sorry for the distress experienced by Mr Cartwright’s family and will carefully consider the coroner’s findings and recommendations before providing a formal response to the attorney general,” a spokesperson said.
A spokesperson for the current NSW corrections minister, Anoulack Chanthivong, said the death was a “tragic loss”. He expressed the government’s deepest sympathies to Cartwright’s family and loved ones.
The spokesperson said a number of reforms have already been implemented since Cartwright’s death, including improved observations, trials of proof-of-life monitoring technology and a review of policies regarding the restriction of water to prison cells. Corrective Services NSW will also aim to improve its supervision of inmates held in assessment cells for more than 48 hours.
“Corrective Services NSW takes seriously its duty of care to inmates who they are tasked with keeping safe and secure while under supervision,” the spokesperson said. “Any conduct that jeopardises the health or wellbeing of inmates or staff is completely unacceptable and inconsistent with the extremely high standard of behaviour that the minister expects.”
Cartwright’s family have told the Guardian that his treatment was incomprehensible. They are now taking legal action against the state government.
The case occurred in 2021 under the previous government.
