WARNING: This story contains distressing elements, including references to suicide and self-harm.
A prison watchdog has found systemic racism likely led to an Aboriginal woman's self-harm incident at the Alexander Maconochie Centre being treated as a security response, after she was pepper sprayed, handcuffed and strip searched.
Following a review, the ACT Inspector of Custodial Services has tabled 11 findings and 4 recommendations, saying systemic racism and likely unconscious bias led to the response.
In the watchdog's critical incident report, it said the ACT government noted areas where cultural considerations should have been considered, however it rejected the findings of systemic racism in the draft based on "a single event".
Findings of culturally inappropriate response
On the morning of July 24 2025, the Aboriginal woman asked through her cell’s intercom when her prescribed mental health medication would be delivered, concerned it had not been arriving on time, according to the incident review.
She had been experiencing “a significant pattern of deteriorating mental health” for weeks, and staff were aware of her challenges with mental health, self-harm and suicide ideation.
She had been placed into solitary confinement for 28 days – comprising isolation for at least 22 hours a day without meaningful human interaction – after climbing onto the Centre’s roof in protest of the rejection of her request to attend the centre’s NAIDOC Day celebrations.
By mid-morning she told officers she needed cultural and mental health support, having still not received her medication.
She was also denied attendance an Aboriginal Cultural Art Program, citing disciplinary reasons.
The self-harm incident that subsequently occurred was responded to with the woman being pepper sprayed by two officers. She then fell to the floor and briefly lost consciousness.
The findings detail an ongoing presence of up to 19 Correction Officers, with at least 13 escorting her to a Crisis Support Unit.
There, according to the report, she was strip-searched without reasonable grounds and in ear-shot of male detainees, against cultural safety practices.
The review also found the decontamination shower fell 7 minutes short of the required 15 minutes, with the woman saying she could feel the effects of the pepper spray in her skin and hair for days after.
The Custodial Inspector has also pointed to the one-day delay of the medical assessment as a “near-miss scenario”, given the possibility of serious injury.
Systemic issues compounded in incident, Inspector says
Rebecca Minty, Inspector of Custodial Services for the ACT, told NITV the response involved several issues, and the woman had said her mental health had been impacted by the use of Oleoresin Capsicum (OC) spray.
“This is really a situation of mental health crisis, and in my view, it should prompt a therapeutic response rather than a security response,” she said.
“If a person is directing the harm towards themselves rather than anyone else, it is entirely inappropriate in my view that OC spray be used in that situation.”
She says that while staff were quick to intervene, people in custody facing distress and not at immediate risk to others need an approach that focuses on support.
“For Aboriginal and Torres Strait Islander People in detention, connection to culture and kin is not an optional extra.
"Limiting access to culturally significant activities can have real impacts on wellbeing.”
Other issues include gaps in available CCTV footage, delayed medical attention, and the lack of culturally safe and responsive services.
The review has also said the denial of conditional access to culture and absence of culturally informed decisions showed the presence of systemic issues, and “rather than a single event, this was a cascading series of decisions and circumstances that in sum demonstrate systemic racism and implicit bias.”
The recommendations include ensuring pepper spray is not in response to attempted self-harm, reviewing if the Centre’s responses and knowledge of reducing self-harm were to standard, and taking active steps to enhancing trauma-informed approaches.
Other issues include the calling of a Code Black, used for instances of harm against staff, as opposed to a Code Blue, used for life-threatening medical assistance.
In a joint statement the ACT Minister for Aboriginal and Torres Strait Islander Affairs Suzanne Orr and the ACT Minister for Corrections Marisa Paterson acknowledged the seriousness of the review.
“This incident is profoundly distressing, and we acknowledge the harm experienced by the individual involved," she said.
"We recognise the importance of ensuring responses to self harm are safe, trauma informed, and consistent with human rights obligations. The ACT Government will carefully consider the findings and recommendations and will provide a formal response in due course.”
