Canberra jail failed to check for ligature materials before inmate's death
Coroner found unrestricted access to ligature-making materials and poor observation directly contributed to Justin Cordy's death.
A coronial inquest into the death of 34-year-old Justin James Cordy at Canberra's Alexander Maconochie Centre found multiple failures that preceded his suicide. Cordy was in custody less than 24 hours before he died on February 26, 2023.
Coroner Lucinda Wilson found he was able to bring materials to make a ligature into his cell and keep them overnight without prison staff knowing. Wilson said prison officers failed to observe him with these materials, and this directly contributed to his death.
The inquest also uncovered failures to share mental health alerts between police and arresting officers, and gaps in mental health services.
- 34 years old
- Inmate age
- February 26, 2023
- Death date
- Less than 24 hours
- Custody duration
- More than 3 years after death
- Inquest findings delay
Why it mattersThe findings expose serious gaps in how Australian prisons monitor vulnerable inmates and manage mental health risks in custody.
AustraliaCanberra jail and other Australian prisons will likely change how they screen for and manage self-harm risks, affecting how custody facilities protect inmates.
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