Inquest probes prison mental-health failures after First Nations mother’s suicide

A coronial inquest into the death of Monique, a 29-year-old First Nations mother of five, examined whether the prison and hospital systems provided her with the same standard of mental-health care available in the community. After entering custody on 12 December 2024, Monique, who was on medication for sleep, chronic pain, anxiety and depression, began expressing suicidal thoughts and hearing voices, repeatedly asking for her regular medicines, yet her community health records were never supplied.

Following a suicide attempt she was transferred to Westmead Hospital, where staff treated only her physical injuries and did not refer her to the mental-health team or prescribe psychotropic drugs, a practice said to be standard for prisoners. The inquest heard that no psychiatrist or suicide-outreach team saw her during her three weeks in custody, and that prison staff were stretched thin, with no psychologist assigned and only one outreach member on duty over the holiday period.

Monique was placed in segregation after an attempted escape, denied a cellmate, and died alone in a cell lacking CCTV and with ligature points, just two days before a segregation order was to end. The hearing also raised questions about the handling of an apprehended violence order served hours before her death.