The body of Robert Harold Gerard, 47, was found in the bathroom of the medium security section of Risdon Prison, north of Hobart, in the early hours of May 23, 2022.
Mr Gerard, who had a long history of mental illness and substance abuse, had pleaded not guilty to murdering a 70-year-old man and wounding his wife four months earlier.
A consultant forensic psychiatrist who gave evidence at an inquest into Mr Gerard’s death said mental health resources at Tasmanian prison facilities at the time were the lowest he’d seen in any developed country.
Dr Rajan Darjee said when Mr Gerard died there was only one permanent psychiatrist working in the Risdon Prison complex.
When he gave evidence in late 2023, Dr Darjee said there were 80-90 mental health patients requiring reviews.
There was one psychiatrist, one psychiatric liaison nurse and one nurse to share the caseload.
Dr Darjee said previous reviews had shown 12-15 mental health staff, not including a psychiatrist, were required.
In the inquest findings published on Monday, Coroner Simon Cooper said the medical treatment and care provided to Mr Gerard was reasonable.
However, he recommended an “urgent” review into the level of mental health services provided to inmates to ensure national and United Nations obligations were being met.
A spokesman for Tasmania’s justice department said the coroner’s findings and recommendations were being closely reviewed.
Mr Gerard was experiencing psychosis and delusions in the lead-up to the alleged murder and received treatment for paranoid schizophrenia in prison.
Mr Cooper said Mr Gerard had missed an appointment with a psychiatrist in April because they were on leave.
“Almost two months had elapsed between the time of Mr Gerard’s last psychiatric assessment … and his death,” Mr Cooper said.
“Had there been more resources he may have been seen more frequently by a psychiatrist.”
Mr. Cooper noted that the section of the prison where Mr. Gerard was housed was locked down 79 times in the 22 days before his death.
Mr Cooper also made several recommendations for prison design changes to reduce the risk of suicide.
Liberal minister Felix Ellis said the state government would examine the coroner’s report.
“Any death… particularly a death in custody is a tragedy,” he told reporters.
“As a government, we’re tough on crime but we also want to be strong on rehabilitation.”
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