Guardian Australia has this week published an investigative series revealing the shocking death toll from inaction on known hanging points in Australian prisons.
The investigation found that 57 deaths have occurred using ligature points that were known to authorities but not removed, often despite stark warnings about the dangers they posed.
In one case, the same hanging point was used in aQueenslandprison in 10 hanging deaths across almost two decades, despite repeated calls for it to be addressed.
Each state was asked why the hanging points were not removed and what it was doing to make prisons safe.
Here are the responses in full:
Queensland Corrective Services takes the safety and wellbeing of prisoners in custody very seriously and all deaths in custody are subject to police investigation and Coronial inquest.
Several protective measures are in place to prevent prisoners from harming themselves, including comprehensive suicide risk assessment and management plans which inform where prisoners are accommodated.
All frontline QCS officers undertake mandatory training in suicide prevention and QCS’ Mental Health Strategy 2022-2027 is identifying people in custody or supervision with mental ill health and assessing them early, to provide them with the supports and services needed including necessary supervision, monitoring and access to medical, psychologist, and other relevant supports.
In addition, QCS is always working to ensure the infrastructure in each correctional facility minimises risks for self-harm or suicide.
In Queensland, 92.9% of all secure cells have a safer cell design and prisoners identified as being at risk of self-harm are placed in the most appropriate accommodation to keep them safe. This equates to 7,550 (95.7%) built beds within secure safer cells.
When the new Lockyer Valley Correctional Centre comes on-line, 93.5% of Queensland secure cells will be safer cell design compliant. This will equate to 96.2% built beds within secure safer cells.
Corrective Services NSW is committed to reducing all preventable deaths in custody and continually seeks to improve the design and safety of correctional centres.
The NSW Government has invested $16 million to make our prisons safer by removing ligature points.
This will continue the extensive work that has already been undertaken across several facilities as part of our coordinated statewide infrastructure program to refurbish cells and remove obvious ligature points or cell furniture that could pose a self-harm risk. This has included the removal of ligature points from almost 800 cells, as well as replacing cell doors, grills, beds, basins and tapware. An additional 145 cells are expected to be completed by July 2025.
In addition to ligature removal and refurbishments, Corrective Services NSW has well-established policies and procedures for the care and management of inmates identified as being at risk of self-harm or suicide.
The Department of Justice has been undertaking a comprehensive program of ligature minimisation in the State’s prisons since 2005, noting that it is not possible to achieve the complete elimination of all ligature points.
The program to increase the number of fully ligature-minimised cells across the custodial estate is ongoing, with priority given to facilities with the highest risk and need.
This work is also complemented by suicide prevention programs and risk minimisation strategies.
The Department is expanding the range of services provided to meet the needs of an increased prisoner population, including those with complex mental health issues.
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This includes the Casuarina Prison Stage 2 Expansion Project which will deliver critical new infrastructure to meet future demands of high-needs or at-risk prisoners and will house 36 special purpose beds in a Mental Health Support Unit with dedicated therapeutic accommodation for prisoners with psychiatric conditions.
The Department also established the Clinical Workforce Committee to develop strategies to retain specialist health and mental health staff in Corrective services.
The Department is continuously strengthening protocols for managing recommendations made by oversight bodies, including the Coroners Court ofWestern Australia.
The Department is committed to addressing all supported Coronial recommendations and considers all recommendations on a case-by-case basis.
If there are practical barriers to implementing proposed recommendations, the Department works with the Coroners Court to develop alternative strategies to achieve practical outcomes that address the intent of the original recommendation.
Every death in custody is a tragedy for the person’s family, friends and community. It is also extremely distressing for DCS staff and first responders.
DCS recognises the importance of reducing risks associated with prisoner self-harm and suicide and is committed to enhancing safe accommodation at all sites.
The Department has acted on Coronial recommendations to remove hanging points and over the last decade has invested about $200 million in new infrastructure and upgrades to existing infrastructure to ensure safe cell design in prisons across the state.
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New builds at the Adelaide Women’s Prison and Yatala Labour Prison which are currently underway also adhere to the safe cell standard.
Upgrades to aging infrastructure and cells at various sites continue to be undertaken.
A range of programs have also been implemented to identify those prisoners who are at most risk, which includes targeted culturally appropriate services for Aboriginal prisoners.
TheTasmaniaPrison Service (TPS) has adopted a risk-based approach which has resulted in the removal of many hanging points across prisons.
All new builds in the TPS comply with prison infrastructure standards and are constructed to ensure no hanging points exist.
All cells for managing maximum-security prisoners and those considered to be at risk of SASH are constructed to ensure that no hanging points exist.
The TPS takes an individualised approach to SASH risk and the safety of prisoners at risk of SASH is driven by structured professional judgment incorporating individual assessments, which takes into account evidence-based practice, research, and a personal assessment of the individual from a multi-disciplinary approach.
Prisoners who are considered at risk of SASH following assessment are housed in units of the prison where the risk of self-harm is mitigated through various measures including decisions to limit a prisoner’s movements or limit their access to clothing items, footwear, cutlery, linen or other items that may be used to cause harm.
This approach is consistent with various human rights principles including treating each prisoner as an individual, minimising differences between prison life and liberty and not assuming that all prisoners are at risk of SASH.
Prisoners at risk of SASH are provided mental health supports and regular interventions.
We know that people coming into custody can have complex mental health issues. We take these risks very seriously and ensure prisoners are provided with the support they need and are housed in appropriate accommodation.
We have strong measures in place to reduce self-harm and suicide, including specialist mental health services and clinicians on-site in prisons. Staff are also trained to identify at-risk people and make referrals.
The Victorian Government continues to invest in modern prison facilities to improve the rehabilitation and safety of people in custody, such as the new Western Plains Correctional Centre opening in July.
The ACT Government is committed to continuous improvement to minimise harm in our correctional facilities. ACT Corrective Services has rigorous processes in place to ensure it maintains the highest standards of care for all people in custody.
The Alexander Maconochie Centre (AMC) has a Facilities Management team, which consists of highly experienced trade professionals who are well-versed in working with Custodial Operations to identify and address obvious ligature risks as part of routine maintenance and repair activities. Where ligature risks are identified, further assessments are conducted to determine remedial action required to suitably address the risk. Work required is predominantly managed by this team and frequently funded through existing operational expenditure allocations. It is therefore difficult to determine how much has been spent on ligature point prevention and remediation. However, where ligature risks have been addressed as part of a defined project, the associated costs/funding are included below.
ACT Corrective Services had been provided separate reports by the ACT Coroners Court and ACT Inspector for Custodial Services into Mr Rich’s death. These reports provided important insights to help prevent harmful and tragic outcomes from being repeated. Significant work has been undertaken to address the risks identified in the reports, including:
upgrades to the Management Unit’s rear cell doors, which were completed in May-June 2022 and cost approximately $3,500-$4,500.
the commissioning of a further review into the Management Unit’s rear cell doors, which is currently underway. As outlined in the ACT Government’s Response to the Coroner’s report, ACTCS is committed to publishing the findings to the greatest extent possible once the review is complete.
release of an updated Intervention Hoffman Knife Operating Procedure, which became effective in November 2023 and states Hoffman knives are now personally issued to correctional officers.
development of an ACT Corrective Services Suicide Prevention Framework, which was released in April 2025 and guides how ACT Corrective Services staff work with clients, both in the custodial and community correctional environments, to reduce suicide and suicidal behaviours,
Other work to reduce cell ligature points that has been carried out or is being planned includes, but is not limited to:
upgrades to cell furniture in the Management Unit, with $3,270 spent to repair identified ligature point risks.
upgrades to cell furniture across various accommodation units, including to reduce potential ligature risks. This work is scheduled to be completed by May 2026, with a total estimated project cost of $174,440.
Following recommendations from the NT Coroner in 2017, works to mitigate the risk of similar incidents by removing the ceiling fans [at Darwin Correctional Centre] was completed in September 2020.