Following the suicide of an alleged murderer on remand at Risdon Prison, a coroner says the jail’s mental health services need to undergo an urgent review.
Coroner Robert Webster’s comments came on Monday as he handed down his findings into the prison suicide of Robert Harold Gerard, who died in May 2022 while being held on remand for murder.
In his findings, Mr Webster noted evidence from a consultant forensic psychiatrist that Risdon Prison, its mental health facility, the Wilfred Lopes Centre, and their associated services had the lowest level of resourcing he’d experienced “in any developed country”.
Mr Gerard spent time in both facilities while on remand in 2021 and 2022.
He was due to stand trial after pleading not guilty to the murder of 70-year-old parliamentary driver Michael Hawkes at Reedy Marsh, and the wounding of his wife Judith, in January 2021.
Police manning a roadblock at Parkham, where Mr Gerard was ultimately apprehended.
Mr Webster said the Hawkes were known to Mr Gerard, and it was believed Mr Gerard was in the grips of a delusion that the couple had kidnapped his son.
Mr Gerard’s girlfriend said he had been suicidal as he didn’t know where his son was, and the coroner noted Mr Gerard also suffered from psychosis and a long history of substance abuse.
After being taken into custody and “clearly very unwell”, Mr Gerard was assessed as likely suffering paranoid schizophrenia, “with prominent grandiose and religious themes, as well as bizarre and persecutory themes, along with auditory hallucinations”.
He was placed on a medication regime and a level 4 two-hourly suicide watch, and was transferred to the Wilfred Lopes Center a few months later in April.
While at the centre, Mr Gerard told doctors he believed Mr Hawkes was a “lizard man” who had kidnapped, tortured and murdered his son, that the “holy ghost” had taken over his voice, and that he needed to avenge his son.
In July that year, Mr Gerard’s condition was assessed as having improved, with his suicide risk de-escalated to a level 5 – with a minimum of three staff interactions per day – and returned to the general prison population.
Reedy Marsh locals heard rumors of a sighting of Robert Gerard, who remained on the run through bushland for 24 hours after the death of Michael Hawkes. Picture: Grant Wells
But towards the end of the year, Mr Gerard presented to doctors as unkempt, “flat and unhappy”, with little energy and hopeless about the future.
He said the medication he was on made him “a veggie”, and by January 2022, kept to himself, often did not come out of his cell, stopped eating and began to appear gaunt.
Mr Webster said Mr Gerard died by suicide in the Kara Delta unit, which only houses male prisoners placed on a level 5 suicide watch – and which had undergone 79 lockdowns in the 22 days leading up to his death.
Mr Webster said while Mr Gerard received reasonable medical care and treatment in prison, he noted evidence from consultant forensic psychiatrist Rajan Darjee, who said Risdon had 80 to 90 mental health patients needing review by the mental health team – but only one psychiatrist, one consultant forensic psychiatrist and one other nurse.
Dr Darjee said two previous reviews showed 12 to 15 mental health staff were needed for that workload, not including a psychiatrist.
He recommended an urgent review of Risdon’s mental health services be conducted, in order to ensure the prison was meeting its international treaty obligations under the United Nations Standard Minimum Rules for the Treatment of Prisoners, known as the Nelson Mandela Rules.
Mr Webster also made another two specific recommendations to reduce the risk of suicide by the same method that Mr Gerard took his life.
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