Mother's quest for change as dozens of inquests reveal mental health failures

Dozens of inquests reveal failures in mental health care behind prison walls Tracy Mackander thought the coronial inquest into her son Bailey's death in custody would bring real change. It only brought more heartache. An ABC investigation can reveal a prison system that is failing the most vulnerable. Warning: This story includes the name and images of Indigenous people who have died, used with their families' permission. It also references suicide. When Tracy Mackander thinks about her son, she tries not to think about prison. She thinks of the beach where he grew up and felt most free. Bailey Mackander had a big heart. He loved skateboarding and surfing the glistening blue water around Nelson Bay. He was a devoted brother in a large blended family. "He was funny, loving and sensitive. He loved his family, and we loved him unconditionally," Tracy said. But Bailey also had his struggles. When he was 14, his baby sister Molly died. He developed anxiety, started taking drugs and began getting into trouble. His addiction deepened and by the time he was 20, he had spent periods in rehab, youth detention and prison. He spent his last stretch in custody at Kariong Correctional Centre in Gosford, New South Wales, where he was the second-youngest prisoner. Prison was hard for Bailey. Really hard. He had previously been assaulted by other inmates and would call his mother twice a day, often in distress. "Just the desperation in his voice, as a mum you know he wanted help," Tracy said. "He would cry, it was absolutely just soul-destroying." Then, on November 4, 2019, Bailey called his mother again. He had been moved into an assessment cell after telling a psychologist he was having suicidal thoughts. It meant spending hours alone, something Bailey dreaded. He told Tracy he wasn't coping and feared he would have a panic attack. She promised she'd call the prison to get him help. That was the last conversation they had. The next day, Bailey, shackled at his hands and feet, would make a desperate bid for escape from hospital. It wasn't until two years later that Tracy walked into the NSW Coroners Court, hoping an inquest would finally explain what had happened to her son. "I knew nothing could bring him home, but I hoped that if the system could identify where it had failed Bailey, then maybe another family would not have to go through what I have," she said. "I wanted Bailey's death to mean something." When the coroner, Magistrate Elaine Truscott, delivered her findings she was moved to tears. She described Bailey as "a young, gentle man who was really still a boy". The coroner found a litany of failures had contributed to Bailey's death. These excerpts come from her coronial findings. She described the inquest as "a convincing example of how prisons are no place for people like Bailey". But prisons are full of people like Bailey. For the first time, the ABC can reveal the scale of the mental health crisis taking place behind prison walls. The ABC examined 249 coronial inquests into deaths in NSW prison custody since 2015. The following excerpts come from those findings. Of those inquests, 48, or close to one in five, identified failures in the care or supervision of people with a diagnosed mental illness. In 14 of those cases, the person who died, like Bailey, a Wiradjuri man, was Indigenous. Inquest after inquest found the same thing: people with mental illness are vastly over-represented in prison and the health care they receive is severely underfunded. Bailey Mackander's inquest was no exception. Warning signs were missed After he confessed to suicidal thoughts, it was decided Bailey would be sent to an assessment cell where he could be monitored. The psychologist who recommended the cell was right to recognise Bailey was at risk, the coroner found. But she hadn't consulted his prison health records, so she didn't know he had a history of anxiety and panic attacks and had recently started taking antidepressants. And she didn't contact Tracy for her insights on how to help Bailey; in fact, the coroner found, she refused to take her call. Left alone, Bailey went downhill fast. He buzzed the intercom for the next two hours, making 67 calls, often highly distressed, begging to see the psychologist, saying he couldn't breathe. The coroner heard he was likely having a panic attack. Later that day he was taken to hospital for a chest X-ray, then returned to his cell. The next morning, Bailey's mental health was reviewed by a Risk Intervention Team, known as a RIT, made up of two Corrections staff and a nurse. The psychologist was not a member of the team. Bailey told them he had no intention of harming himself and begged to be released, describing his night alone in the cell as "the worst of his life". The team discussed halfway options, such as letting him mix with others in the yard during the day or buddying him up with a friend. But a senior guard who wasn't even on the team got involved and effectively "vetoed” their decision-making, the coroner said. Even though he had no training in RITs, the coroner found he "dictated" they had only two options: leave Bailey in the cell or release him from the RIT back into the prison. "He imposed himself on the meeting and due to his status, he overrode the RIT review process," the coroner said. The decision to put and keep Bailey in the cell was not necessary or appropriate, she said. The ABC found 20 coronial inquests that identified failings in the way a prisoner's mental health risks were screened and assessed. Often it meant vulnerable prisoners were placed alone in cells with the means to take their own lives, or dangerous prisoners were placed in cells with vulnerable inmates. Deemed his best option, isolation was destroying Bailey Putting Bailey in the assessment cell was meant to be a measure of last resort. It was under constant CCTV surveillance, with lights on around the clock. Bailey had no access to open air or an exercise yard and spent long periods alone. Forensic psychiatrist Kerri Eagle told the inquest the decision to isolate a suicidal prisoner was "unique to correctional settings". "You may be making the problem worse, you may be increasing the distress, increasing the hopelessness," Dr Eagle said. When another inmate was allowed to visit Bailey, he found him pacing in his cell, inconsolable. "I asked him why he was terrified and he said it felt to him like he was in the horror film Saw." On Bailey's second day, he was allowed no phone calls or visits at all. "Nobody recognised or considered that more harm than good was being done to Bailey," the coroner said. "He was expected to tough it out. Suck it up." Bailey tried to tell prison staff what isolation was doing to him. "You've got to get me out of here, this is fucking making me sick. It is stressing me out, please." These intercom calls made for distressing listening. One five and a half minute call, during which Bailey said he was choking and pleaded and prayed for help, went unanswered. A prison official involved in investigating his death was so distraught by the task of transcribing the calls they were unable to keep working. The response Bailey received from guards was at times "demeaning and somewhat punitive", said the coroner. "Bailey was told that if he continued being distressed in the cell he would be in there for much longer," she said. The ABC has found 14 coronial inquests where inmates with mental illness were found to be poorly supervised by correctional officers. Observations that weren't performed, health forms that weren’t checked, CCTV vision that wasn't properly watched. Guards who simply failed to recognise medical emergencies before it was too late. Who was looking out for him? Bailey was surrounded by people responsible for his care, but the information about his deteriorating condition did not consistently reach them. The psychologist who treated him said she never heard yelling from the cell, didn't know he had repeatedly begged to speak to her and said she hadn't refused to see him. The coroner didn't accept this, preferring a guard’s account that she had heard Bailey but wouldn't see him for fear of escalating him further. Prison staff dodged or failed to answer another three "desperate” calls from Tracy the following day. A nurse who treated Bailey, including calling paramedics for him on his second day, was a dedicated nurse "attempting to fulfil an overwhelming role" under "tremendous pressure", the coroner said. The nurse agreed she could have expedited a mental health assessment for Bailey. But she told the inquest he never should have been at Kariong, given his vulnerabilities. Kariong had no afternoon nursing shift, no drug and alcohol services and no mental health nurse. Prisoners are meant to receive the same standard of mental health care as they would in the community. But the ABC found deficiencies in the clinical care provided to prisoners with mental illness in 27 inquests. They included prisoners whose medication wasn't adequately reviewed, missed doses of crucial meds that weren't followed up, and people who weren't transferred or referred for the specialist care they urgently needed. Help that came too late Specialist mental health services at Bailey's prison were already stretched, with a quarter of prisoners on the waitlist for a mental health assessment. Bailey had been referred for weekly counselling. But it took nine weeks for him to see a psychologist, on the day he was sent to the assessment cell. The ABC found 29 coronial inquests with evidence of prisoners facing an unacceptable wait time to get the health care they needed. Severely ill inmates who died while on the waitlist for a mental health bed. Inmates with schizophrenia who rarely or never saw a psychiatrist for their entire time in custody. A GP serving an entire prison for only one day a week for six hours. A psychiatrist available only four hours a week in a prison with hundreds on the waitlist. What happened to Bailey? As Bailey became increasingly desperate at the end of his second day in the cell, he swallowed stones and told the guards they were batteries and razor blades. After being discharged from hospital he made a dash for escape and hurtled over the nearby wall. He didn’t know it was an 8-metre drop below. The coroner found Bailey was "being driven by sudden impulse and emotion". "He was about to enter the escort vehicle to return to the cell, without any certainty that he would be discharged from that cell the following day," she said. Bailey was critically injured and died two days later. When the coroner handed down her findings she had hoped her words might bring about some change. "These findings and recommendations will not stop them sending young Baileys to prison," she said. "And I suspect they will not even result in better mental health and psychological support in prisons, which are full of people who need it. "But perhaps they will save one or two from being placed in RIT cells to battle their own demons alone." She made a series of recommendations aimed at preventing another death like Bailey's. Corrections accepted most of them but refused to support five that were aimed at making RIT cells safer. They would have ensured RIT teams had a psychologist on the panel or at least their advice, that inmates on RITs had access to a support person, and that guards monitoring assessment cells had clear guidance on how to document and manage any decline in an inmate's health. This was not the only inquest in which Corrections rejected the advice of the coroner. Among the 48 coronial inquests, there were 32 in which the coroner made a recommendation to Corrections NSW and where the six-month deadline for a response had passed. In 10 of those cases, Corrections refused to support the recommendations in full. "Why do they have these inquests if then nothing is going to change?" Tracy said. Another family, another inquest A year after these recommendations were handed down, 47-year-old Aboriginal woman Tammy Shipley died in a Sydney prison after spending nine days alone in a monitored RIT cell. Tracy says Tammy's death shows the lessons from Bailey's death weren't learned. "Bailey can't be saved now but somebody else's Bailey can be, and that's why these recommendations matter," she said. "I don't want another mother standing where I'm standing years from now saying exactly the same thing." Nerita Waight, head of the peak body representing Indigenous legal services NATSILS, says many families question what inquests have achieved. "If you speak to any Aboriginal family who has gone through the coronial process, they will tell you that it didn't lead to them feeling a sense of justice because, inevitably, no-one is really held responsible," she said. "There is no guarantee that recommendations will be enacted and that deaths will be prevented in future." Asked about its failure to accept some recommendations, a Corrective Services NSW (CSNSW) spokesperson told the ABC it carefully considers each one. "CSNSW has strengthened its engagement with the Coroners Court to provide a clearer understanding of the correctional environment," they said in a statement. "This will support recommendations being made that deliver better outcomes and can be effectively implemented." They said CSNSW followed strict legislative frameworks to manage people in prison safely, many of whom entered with longstanding and unaddressed mental health needs. "Specialist teams, including the Risk Intervention Team, assess and monitor inmates, using their training, set guidelines and observational skills to form their judgements," they said. "We are progressing reforms to strengthen how we identify and respond to people in distress and improve collaboration between custodial staff and health services." A spokesperson for Justice Health, the government agency that employs prison nurses and doctors, said it had improved universal mental health screening and implemented evidence-based suicide risk assessment and safety planning. It had introduced a virtual psychiatry clinic, they said, as well as a Suicide Prevention Outreach Team and new training for health staff to recognise deteriorating mental health. 'I wanted change' For Tracy, sitting in the courtroom surrounded by lawyers in suits, watching people responsible for the care of her son giving evidence was painful. "It's like reliving his death each and every day that you walk into that courtroom," she said. "I still have really bad trauma from that experience." It took more than two years after Bailey's death for his family to receive the coroner's findings, a not-unusual timeline within the NSW coronial system. Tracy sat through every day of the hearings. "I wanted answers. I wanted accountability, I wanted change," she said. "But I didn’t get any of it." How we investigated this story The Indigenous Affairs Team used AI to scour hundreds of coronial findings into NSW deaths in prison custody. We downloaded the open-source findings via links collated by the University of Queensland Deaths in Custody project. We then cross-checked these against our own scrape of the New South Wales coroner's website. We loaded the findings from January 2015 to September 2026 into an AI program and asked it to identify patterns among the deaths of people with schizophrenia or other mental illness. We then read and fact-checked every inquest finding that identified deficiencies in their care or supervision. - Share options - Copy link - X (formerly Twitter)