WARNING: This story contains details that may be distressing to some readers, and images of a person who has died.
NSW Deputy Coroner Elaine Truscott opened the hearing by paying her respects to the Traditional Owners of the land, “which continue to be important today” and acknowledged Elders present in courtroom one of the NSW Coroner’s Court.
Circumstances were avoidable
Gosford Detectives’ Senior Constable Jesse Mears told the court on Monday the circumstances leading to Bailey’s death were “avoidable”.
Mr Mackander died on 5 November 2019 from injuries sustained after he fell 10 metres onto a concrete path at Gosford Hospital, while two prison guards were escorting him back to Kariong Correctional Centre.
CCTV footage played in court showed Mr Mackander barefoot and shackled while corrections officers Ricky Slingsby and Wheturangi Uerata appeared to be metres away from him as they walked across the emergency bay before Bailey jumped over the wall.
Senior corrective services officer Peter Cargill told the court on Thursday he had “no concern of Bailey’s escape risk”, despite telling guards to watch him closely because he was impulsive.
Mr Cargil told the court he didn’t include an explicit requirement to hold Bailey during the escort but said it was in his view that the guards should have held onto him.
The gaps between corrective officers and Mr Mackander was one of the avoidable circumstances Senior Constable Mears identified, along with the medical treatment Mr Mackander received in hospital, and the unfenced wall at the emergency bay.
The court was shown photographs of the emergency bay taken by Senior Constable Mears, who said the large black grill fence evident in the pictures “wasn’t there” days earlier when Mr Mackander fell.
Mr Mackander was taken to the hospital on 5 November after he reported swallowing batteries and razor blades while he was in an observation cell at Kariong Correctional Centre.
Bailey told Mr Cargill the razor blades and batteries he swallowed were taken from inmate *John Brown* in cell 3 who brought them from Parklea Correctional Centre.
Taunted in observation cell
Mr Cargill told the court he wasn’t informed that Bailey was "knocking up" (calling for assistance via an intercom) for hours on 5 November.
The court later heard that corrective officers turned down the volume of the intercom, used to call staff for medical emergencies, so they could watch the Melbourne cup.
Counsel assisting Tracey Stevens asked, “If you were played a knock up call would you be able to identify your voice”?
An audio recording of a knock up call was played in court.
Guard: Guess whose time it is for dinner?
Bailey: I don’t know.
Guard: Have you had dinner yet?
Guard: Guess whose time it is for dinner… guess!
Guard: … mine.
Laughter broke out in the courtroom as Mr Cargill said he didn’t know if the guard’s voice in the audio recording was his own.
Bailey’s father David Mackander stood up with his arms crossed to face Mr Cargill.
Mr Cargil told the court he visited Bailey’s cell on 5 November to achieve a positive interaction as he was “distressed and upset”, and wasn’t his “normal calm self”.
Mr Cargill recalled Bailey saying he wanted two towels so he could have a shower.
“And I said I want something too, mate. I want the cell clean,” he said.
Mr Cargill then gave Bailey a mop and a bucket.
Ms Stevens asked if it was appropriate for an inmate who’s at risk of suicide to be given a mop and a bucket. She also asked if Bailey had to clean his cell to have a shower.
In response, Mr Cargill told the court it was to encourage positive behaviour.
The court was then shown CCTV footage of Mr Cargill removing a blanket from Bailey’s cell.
When asked why he did this, Mr Cargil said “it might have been dirty and needed to be replaced”.
Although, Mr Cargill told the court he couldn’t recall if the blanket was replaced.
Bailey “cried wolf": officer
The inquest heard Mr Cargill told Mr Slingsby and Mr Uerata that Bailey “cried wolf several times” in his brief before they drove him to Gosford Hospital.
Mr Cargill also told the guards, “we don’t want a death by officer otherwise we’ll have a mountain of paperwork”.
Ms Stevens asked Mr Cargill what he meant by the suggestion that Bailey “cried wolf”.
“If he said he’s in pain, maybe not. If he said he’s swallowed razors, maybe not,” Mr Cargill responded.
“He’s not trustworthy. Don’t trust him.”
The court heard Mr Cargill didn’t consider that his brief accusing Bailey of crying wolf would be read by hospital staff.
He told the court Bailey was sent to hospital the day before complaining of pain, but when he got there he asked for medication without informing the doctors of his pain.
Speaking to another incident, Mr Cargill said Bailey had faked being unconscious, which was proven by his reaction when saline was squirted up his nose.
“That’s the second time he’s lying,” Mr Cargill said.
Mr Cargill told the court later that he saw Bailey’s discharge papers from the hospital.
“So you know from the discharge papers that he told doctors about the pain?” Ms Stevens asked.
“Yes,” Mr Cargill responded.
Mr Cargill told the court he was concerned for Bailey’s mental health but didn’t turn his mind to see whether he’d received treatment or help.
Coroner Trustcott asked, “it didn’t occur to you that while he was getting an X-ray, that he should get a mental health assessment”?
“No,” Mr Cargill responded.
“Do you think he should have received a mental health assessment?” Coroner Trustcott asked.
“I think it’s useful if it’s a self-harm issue like he’s bashed his head or something,” Mr Cargil responded.
“What’s the difference between a prisoner bashing his head and eating razor blades?” Coroner Trustcott asked.
Mr Cargil responded that it would be up to the hospital to assess.
Mental health history wasn't checked
The inquest heard on Wednesday that NSW Corrective Services psychologist Dr Erin Hyde decided to send Bailey Mackander to a confined cell without explaining to him why, or how long he would be there.
Dr Hyde told the court that she accepts responsibility for Bailey being placed in an observation cell, which she said she decided after Bailey disclosed daily thoughts of taking his own life.
While she told the court Bailey denied having a plan to end his life, she said it wasn’t convincing.
A phone recording was played of Bailey telling his mother Tracey Mackander he never said such things.
Bailey: I spoke to a counsellor and I said how I was feeling and they put me in a RIT cell. It’s fucked. I can’t do it. I can’t deal with it. I opened up to her and… *crying*
Tracy: How long have they got you in there?
Bailey: I can’t even be in here for 2 seconds, mum.
Tracy: They’ll only keep you there for 24 hours.Why did they put you in there?
Bailey: Because I was upset. I said that on my record, I never ever self-harmed in my life.
Tracy: Do you know what? They can’t keep you in there. The more you work yourself up, the more they’ll think you need to be in there.
Bailey: It’s not like I can go for a run.
Tracy: Do star jumps and push-ups.
Bailey: Then they’ll think I’m even more fucking mental. I don’t even have a blanket. Nothing.
Tracy: I love you so much.
Bailey: I love you. I’ll call you when I can. I love you, mum. Bye.
This court was told this was the last time Bailey spoke to his mother before he died.
At a Prison Officers Vocational Branch monthly meeting, the court heard one of the issues staff raised was that the observation cells at Kariong led to a deterioration in the mental states of inmates.
Coroner Trustcott also told the court officers and unions said, “they are not fit for inmates with mental health issues”.
The court heard Dr Hydes didn’t check Bailey’s medical history and acknowledged that she should have.
As part of the Risk Intervention Team assessment Dr Hydes placed Bailey on, the court heard Bailey was supposed to be assessed within 24 hours.
But Dr Hyde told the court there was no plan for him to be psychologically assessed.
The court heard there is also a requirement that inmates are not to be kept in observation cells for more than 48 hours.
Mr Cargill said the governor told officers in 2017 that “no inmate should be kept there for more than 24 hours and if they are, I’ll come down and drive there myself”.
Mr Cargill told the court he wasn’t aware of the statutory obligation for inmates to have 2 hours outside unless they’re subject to a disciplinary action, which Bailey was not as he was on remand.
Justice Health nurse Lara Georgiou said Dr Hydes told her it would be a good idea for Bailey to be outside before she placed him on a RIT as it was something that he enjoyed, the court heard on Wednesday.
However, Bailey was deprived of spending two hours outdoors during his time in the observation cell.
After Bailey died, Mr Cargill and Dr Hyde said they can’t recall a debriefing of Bailey’s incident at Kariong Correctional Centre.
Mr Cargill told the court the functional manager of the prison, Mr Terry Dolling, only signed for what occurred on 5 November 2019 two days later.
The inquiry continues on 6 July 2021.
Readers seeking support and information about suicide prevention can contact: Lifeline on 13 11 14, the Suicide Call Back Service on 1300 659 467 or find an Aboriginal Medical Service here. There are resources for young people at Headspace Yarn Safe.