A magistrate has made a number of recommendations after an inquiry into the death of Matthew Richard Lothian. Photo: SCM Jeans.
CONTENT WARNING: This story discusses suicide.
Events of the final days of a man who wrested a gun from a prison guard before shooting himself have been revealed as part of the inquest into his death.
Matthew Richard Lothian, 37, was in custody at the South Coast Correctional Centre when he was taken to the Picadilly Centre in Wollongong for medical treatment on Wednesday 6 January 2021.
Despite his wrists and ankles being cuffed, when the Central Coast man exited the Corrective Services NSW (CSNSW) van he was taken in he assaulted one of his guards and stole her handgun.
He threatened passersby and let off shots before shooting himself in the head.
Now a judge has slammed the lack of confidential mental health services in NSW prisons, alongside a “culture of non-compliance” within CSNSW in regards to prisoner escorts and a lack of oversight on the condition of holsters issued to guards escorting prisoners.
State Coroner Magistrate Teresa O’Sullivan said those factors, combined with Matthew’s tendency to be impulsive, a prison assault, and his poor mental health, all contributed to his death.
The court heard Matthew had issues with drugs and alcohol, and as a result issues with the law, since he was a teenager.
He was diagnosed with depression and battled his mental health. His mum believed his demons went deeper, however he did not receive any additional diagnoses.
Matthew had previously served a number of stints in jail, mostly for property offences related to his drug addictions.
At the time of his death he was imprisoned on charges of common assault and of intentionally choking a person, while he was on parole for larceny, assault occasioning actual bodily harm and police pursuit.
He was jailed on 18 September 2020 with his earliest possible release date 8 February 2021.
Matthew was transferred to the Nowra correctional centre, where he began to struggle with his mental health. In December he told staff he was ‘feeling down’ and had thoughts of self-harm and suicide.
He was transferred to the centre’s clinic, where he was kept in isolation, which the court heard was standard practice for inmates who disclosed thoughts of self-harm.
The next day he denied thoughts of self-harm, and said he had lied because he was concerned he would have issues in the main prison population due to his association with the Hells Angels outlaw motorcycle gang. He wanted to return to his cell and leave the clinic.
Later it was found his claims of being a Hells Angel were untrue but his fears of the main population were well-founded – 20 minutes after his release from the clinic he returned with fractures to his face.
The following day Matthew was again assessed for suicide or self-harm risk and found to have no issues.
Over the course of the following week Matthew was assessed by an ophthalmologist and received plastic surgery to repair his face.
Nurses noted his low mood, and on 30 December a psychologist from CSNSW came to speak with him.
Matthew was told he needed to sign a confidentiality waiver in order to speak with the psychologist, and he declined to do so.
In phone calls with his mum in the days leading up to his death, Matthew said he felt abandoned by his family due to his behaviour, and he was “just over it … over life”.
His mum said he was “very sad”.
“Call it mothers’ intuition but I knew something was going on with him as he didn’t seem right,” she said.
On Wednesday 6 January 2021 Matthew was taken for a follow-up appointment in the Picadilly Centre.
Handcuffs, ankle cuffs, a restraining belt and a firearm were all listed as appropriate restraints to use for transporting Matthew, however no pre-escort briefing was conducted.
The officers felt the restraint belt was unnecessary, and did not use one.
Neither of them had formal training in escorting prisoners, and were not familiar with the relevant CSNSW policy; their training was “on the job” and the court heard this was standard, despite not complying with the service’s own policies.
The holster the officer carrying the firearm was issued with was not suitable for the firearm it housed, and had likely previously seen much use on training ranges, however there were no regular checks performed on holsters and no serviceability checklist for the officer to evaluate the holster against.
Magistrate O’Sullivan found these factors were key to allowing Matthew to obtain the pistol after he exited the van.
After a brief struggle he took the pistol and pointed it at the officer, demanding the keys to the van. She took cover behind the car and called triple zero.
Matthew then turned his attention on the other officer and pointed the firearm at him, again demanding keys. The officer hid in a laneway before calling triple zero.
Matthew left the carpark and began to point the pistol at passersby, demanding their cars.
A short time later a police vehicle was flagged down by two witnesses.
The officer drove back towards Matthew and said he was ducking in and out of parked cars and laughing when he found him.
After a shot was fired at his vehicle, the officer radioed for help and urged bystanders to move on.
He then found Matthew lying on his back in a nearby alley, bleeding from the neck from a self-inflicted wound which proved fatal.
Magistrate O’Sullivan found that despite Matthew’s low mood in the lead-up to his death, he did not intend to take his own life. Rather, he committed an impulsive escape attempt, and committed suicide when he realised it was unsuccessful.
She said the lack of confidentiality available through CSNSW’s psychology services contributed to Matthew not receiving the help he needed, and recommended an investigation into whether an alternative, more confidential service could be provided to inmates.
Magistrate O’Sullivan urged CSNSW to develop serviceability criteria for holsters and associated items, and to provide officers with appropriate training, and to undertake an urgent audit of their armoury.
She recognised improvements made by CSNSW to training for officers escorting prisoners off-site.
Anyone experiencing distress can seek immediate advice and support through Lifeline on 13 11 14, Kids Helpline (1800 55 1800), or the Federal Government’s digital mental health gateway, Head to Health.
If you are concerned about suicide, living with someone who is considering suicide, or bereaved by suicide, the Suicide Call Back Service is available at 1300 659 467 or www.suicidecallbackservice.org.au.
Really good and honest article about being a carer. View