Tracy Mackander thought the coronial inquest into her son Bailey's death in custody would bring real change.
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inquest → think → change
It only brought more heartache.
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It → bring → heartache
An ABC investigation can reveal a prison system that is failing the most vulnerable.
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that → reveal → vulnerable
Warning: This story includes the name and images of Indigenous people who have died, used with their families' permission.
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who → include → permission
It also references suicide.
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It → reference → suicide
When Tracy Mackander thinks about her son, she tries not to think about prison.
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she → think → prison
She thinks of the beach where he grew up and felt most free.
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he → think → beach
Bailey Mackander had a big heart.
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Mackander → have → heart
He loved skateboarding and surfing the glistening blue water around Nelson Bay.
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He → love → Bay
He loved his family, and we loved him unconditionally," Tracy said.
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Tracy → love → him
But Bailey also had his struggles.
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Bailey → have → struggles
When he was 14, his baby sister Molly died.
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sister → die → ?
He developed anxiety, started taking drugs and began getting into trouble.
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He → develop → trouble
His addiction deepened and by the time he was 20, he had spent periods in rehab, youth detention and prison.
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he → deepen → rehab
He spent his last stretch in custody at Kariong Correctional Centre in Gosford, New South Wales, where he was the second-youngest prisoner.
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he → spend → Gosford
He had previously been assaulted by other inmates and would call his mother twice a day, often in distress.
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He → assault → 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."
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it → know → help
Then, on November 4, 2019, Bailey called his mother again.
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Bailey → call → mother
He had been moved into an assessment cell after telling a psychologist he was having suicidal thoughts.
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he → move → thoughts
It meant spending hours alone, something Bailey dreaded.
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Bailey → mean → something
He told Tracy he wasn't coping and feared he would have a panic attack.
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he → tell → attack
She promised she'd call the prison to get him help.
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she → promise → help
That was the last conversation they had.
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they → have → ?
The next day, Bailey, shackled at his hands and feet, would make a desperate bid for escape from hospital.
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Bailey → shackle → 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.
"
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what → walk → 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.
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she → know → what
"I wanted Bailey's death to mean something."
When the coroner, Magistrate Elaine Truscott, delivered her findings she was moved to tears.
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she → want → tears
She described Bailey as "a young, gentle man who was really still a boy".
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who → describe → man
The coroner found a litany of failures had contributed to Bailey's death.
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litany → find → death
These excerpts come from her coronial findings.
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excerpts → come → findings
She described the inquest as "a convincing example of how prisons are no place for people like Bailey".
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prisons → describe → Bailey
For the first time, the ABC can reveal the scale of the mental health crisis taking place behind prison walls.
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ABC → reveal → walls
The ABC examined 249 coronial inquests into deaths in NSW prison custody since 2015.
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ABC → examine → 2015
The following excerpts come from those findings.
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excerpts → follow → 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.
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one → identify → illness
In 14 of those cases, the person who died, like Bailey, a Wiradjuri man, was Indigenous.
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who → die → Bailey
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.
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they → find → prison
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.
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he → miss → cell
The psychologist who recommended the cell was right to recognise Bailey was at risk, the coroner found.
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coroner → recommend → risk
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.
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he → consult → antidepressants
…and 96 more, not listed.
The Aporia