South Australian prison officials took seven days to notify support services about the welfare of a vulnerable Aboriginal man being held on remand, despite news reports raising the alarm.
He had been detained under the Mental Health Act and was flown from Port Augusta to Adelaide for treatment.
The man was admitted to the emergency department of the Royal Adelaide Hospital on November 7 because secure mental health facilities were full.
He spent two days shackled to a bed in seclusion, which caused his hands to swell and broke the skin around his wrists – a situation hospital staff described as a “contravention of basic human rights”.
The patient was transferred to a secure mental health facility on November 9 – the same day his treatment was covered by the ABC.
The Aboriginal Legal Rights Movement (ALRM) was not formally notified until November 14.
The organisation administers the Aboriginal Visitor Scheme, the equivalent to the Custody Notification Services that operate in other states.
The scheme was introduced after recommendations from the Royal Commission into Aboriginal Deaths in Custody were handed down in 1996.
Cheryl Axleby, the CEO of the ALRM, said she first heard about the case through media reports.
“We’re supposed to be notified of transfers or injuries,” she told NITV News.
“There was no notification to ALRM and that’s something that will be taken up with the Department of Correctional Services (DCS). We have an MOU which we signed off on in August.”
Ms Axelby said her organisation had "a pretty good working relationship" with the department and was unsure how the situation had come about.
“I don’t know what’s happened internally,” she said.
“I won’t know until I’ve had a conversation about what has transpired and how we ensure this doesn’t happen again.”
One nurse was so concerned about the Aboriginal man’s treatment that she sent a message to the nurses union.
“This situation is the worst abuse of a vulnerable health patient I have ever witnessed as a health professional," she wrote.
DCS refused to be drawn on who it had notified of the transfer and what happened at the hospital.
“The Department for Correctional Services had a responsibility to ensure the person in custody posed no threat to the safety of staff and other patients,” it said in a statement.
“The Department worked closely with Department for Health and Wellbeing staff to care for the person in hospital whilst waiting for the transfer.”
Elizabeth Dabars, head of the Nursing and Midwifery Federation, said Royal Adelaide Hospital has frequently been used as waystation for mental health patients under supervision of prison officials.
“We have heard of cases or many instances of people who are going through the court system being taken over to the RAH emergency department simply because there really isn’t anywhere to put the individual,” she said.
“The minister acknowledges there is an issue, the question remains is what steps the government, the minister and the department are taking to resolve this issue.”
When contacted, SA Health Minister Stephen Wade said he is “acutely aware” of the issue concerning lack of capacity in secure mental facilities.
Mr Wade said the chief psychiatrist and the SA mental health commissioner have been asked to develop a new mental health services plan which is expected to be delivered next year.
For Aboriginal people involved with the prison system, the combination of decisions about when to shackle a patient, what kind of restraints to use and the lack of notification to support organisations can be especially harmful.
“This is not the first incident where we’ve had shackled patients and where an injury caused,” Ms Axleby said.
In 2017, Kunmanara Gibson, 47, who was suffering from chronic health issues died while being held at the Adelaide watch house. In that case, the ALRM was not told about his arrest until after his death.
In 2015, Anthony Stephen Gibson, 53, was in the final stages of throat cancer and pneumonia when he was transferred to the Queen Elizabeth Hospital. For three weeks, Mr Gibson was kept shackled to his bed under the watch of a guard despite pleas by hospital staff to take off his restraints. He remained restrained until just hours before his death.
In 2012, Jacqueline Davis, an Aboriginal woman with spina bifida and extreme mental health issues, spent eight months shackled to her bed in Yatala’s high security G-Division for 22 hours a day after her requests to be transferred to a secure mental health facility were repeatedly denied.
“There need to be opportunities for corrections staff to go to superiors to check with medical staff about removing shackles,” Ms Axelby said.
“You don’t treat people like animals out of context of proper behaviours. You only make things worse. Then our fellas get more charges put on them as a result.”