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REPORT INTO THE DEATH OF TRACY BRANNIGAN Draft 25/03/2013 A LOVED PERSON LOST: Stimulus for change - Let Tracy’s be the last death

Above: Tracy and son

Tracy Brannigan died in prison on Monday 25 February 2013

• Tracy should never have been isolated from her friends’ support in a “high needs” cell

when it was clear that she was drug affected.

• Had the proper services been provided, such as drug rehabilitation, intervention, dry cell

and/ or sufficient monitoring and supervision been provided, Tracy’s life would have

been saved.

• Tracy should have been able to use her prison time effectively for personal

development, but was left frustrated with no computer in her cell or ways to use her

time.

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Table of Contents

1. Introduction

2. Primary concerns

3. Personal life

4. Previous dealings with the law

5. Previous overdoses whilst in custody

6. Drug use whilst in custody

7. Education

8. Opportunities lost

9. Previous examples of avoidable deaths in custody

10. DCS and JH Duty of care

11. Could Tracy’s death have been prevented?

12. Action plan  

 

1. Introduction Tracy was found dead in her cell at Dillwynia Correctional Centre on Monday the 25th

February 2013, the cause of her death was suspected to be a drug overdose. Tracy was due

to be reviewed for parole in late March, if granted she would be released in May 2013.

In the month leading up to her death, Tracy was under constant supervision after having been

charged and placed in segregation. Over a period of six to eight weeks she was required to

provide several target urine tests. As these specific tests are only used when prisoners are on

suspicion of drug use, it reveals that authorities were aware of Tracy’s suspected drug use. In

the days leading up to her death from the 21st February, prison staff were well aware that

Tracy was under the influence of drugs. Evidently, the authorities were mindful of Tracy’s

history with drugs by putting her on sanctions for recent inter-prison charges relating to

suspected contraband and drug use. These misgivings were reinforced on the afternoon of

Sunday, 24 February 2013; during the last visit she would ever receive in custody. It was

blatantly obvious from her movements and slurred speech that she was affected by drugs. Out

of more than 20 women who had visitations on the afternoon of 24th February 2013, Tracy was

the only woman required to wear overalls; she was placed at the front of the visits section with

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prison officers on either side and was directly under the surveillance camera. These actions

are taken when prison authorities suspect drug use. The overwhelming presence of the prison

officers indicated that concern for her safety was vital and demanded a need for constant

surveillance. Prison authorities were right in being suspicious considering that she had overdosed whilst in

custody on a previous occasion only some four months prior. Had they continued to extend

that concern in practice, Tracy could still be alive today. The irony of the situation is that Tracy

was locked in the ‘high needs’ area of the Dillwynia Correctional Centre serving out the

sanctions placed upon her; two-out with a female prisoner on remand, Lauren Lee Ironside,

who also had and was incarcerated for drug related offences.

Tracy’s next of kin has given Justice Action permission to ask questions of DCS to ensure

Tracy’s life was not lost in vain – also to attempt to ensure it does not happen to any other

women serving custodial sentences in the future. During Tracy’s current term, on numerous

occasions, she wrote to Justice Action that she wanted to work with the organisation to assist

in the advocacy being undertaken by Justice Action and similar services, and has said that she

“just needs the knowledge as to how to do that”. Tracy made it known she wanted to be a

voice for women prisoners.

2. Primary concerns

i. Despite continuous surveillance and scrutiny due to Tracy’s known drug use, why was

she being held in the high-needs unit where she was ultimately isolated from her support

people for long periods of time?

ii. Why was it that Tracy was not being monitored, given it was apparent she was involved

in illegal drug use for the period till her death.

iii. The occurrence of Tracy’s death begs the question of how an prisoner like Tracy with

known drug issues, could overdose under the duty of care owed by prison authorities.

iv. Were the NSW Department of Corrective Services and Justice Health (JH) negligent in

their failure to adequately supervise Tracy considering their knowledge of her drug use

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and/or her previous overdoses?

v. Why was Tracy not allowed to pursue her education?

vi. What duty of care did DCS and JH owe to Tracy as an prisoner? 3. Personal Life Tracy Brannigan was considered an extremely intelligent, clever and highly spirited woman.

Vivacious, funny, caring and loving, she was highly respected by other women and advocated

and supported her fellow female prisoners. As testament to this, she was a delegate on the

Inmate Development Committee (IDC) at Silverwater Correctional center. Tracy’s death

occurred shortly before her 42nd birthday. She was about to be reviewed for parole in late

March 2013.

Tracy was the loving daughter of Sandra Kelly and Warren Brannigan, and the fiancée of Jinx

D’Amico. Tracy was also a doting mother to three children; 5 year old Corey-Jack Brannigan,

18 year old Jaidan D’Amico and 24 year old Samantha D’Amico.

Tracy and Jinx D’Amico’s relationship commenced in 1991, they married in 1995 but divorced

in 2001. In 2011 Jinx had proposed for the second time to Tracy and they were to be remarried

upon her release.

With regards to the living arrangements of her

children, Jaidan lives with Tracy’s mother (Sandra

Kelly) while Corey-Jack lives with his paternal

grandparents. The verbal arrangement had been that

the children would be returned to Tracy upon her

release.

Sandra was eagerly awaiting Tracy’s imminent release

as Tracy had plans to enter into a legitimate business

venture, but these plans cannot be fulfilled. On hearing

the distressing news of her daughter’s death, Sandra

had a heart attack and was admitted to hospital. Tracy

will never be able to achieve all her ambitions. Above: Tracy and other son

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4. Previous dealings with the Law Tracy had a long criminal history dating back to early the 90s. Tracy was sentenced to six

years of incarceration starting 23 April 1998, with a non-parole period of four years. In 2000

whilst serving a custodial sentence, Tracy escaped from the Emu Plains Correctional centre,

taking the prisons land cruiser. Approximately four weeks later she was recaptured on the far

north coast of NSW and returned to custody. Ever since, regardless of what the custodial

sentence Tracy served, she was classified as an E classification (escapee). She tried

unsuccessfully during this prison sentence to have this classification reduced, but to no avail.

During the current term of imprisonment whilst at Silverwater Women’s Correctional Centre,

Tracy’s education was put indefinitely on hold as a result of an incident, which involved a drug

and alcohol worker by the name of Marilyn Brown. Many prison workers were privy to Tracy’s

playful nature where she would grab their shirt just below the shoulders and lift it up and down.

Unfortunately, when Tracy performed this ritual on Ms Brown, the woman felt threatened and

escalated the situation. Police immediately charged Tracy in an outside court. This innocent

joke resulted in Tracy receiving an additional 6 months to her existing sentence. This event

had crippling implications on the remainder of her time in custody; she was unable to complete

any drug and alcohol work at Silverwater and it negatively affected her visitation rights. With a

sexual assault charge on her record it meant that her youngest son Corey-Jack was unable to

visit his mother without additional supervision as he was under the age of 16. As a result Tracy

could only see her son when he visited the prison with a volunteer from Shine for Kids

(approximately every eight weeks) or when Tracy’s mother Sandra was able to bring him. 5. Previous overdoses whilst in custody In statements by other prisoners Tracy overdosed on four separate occasions whilst in prison

during her last custodial sentence.

One such occasion occurred on 20 October 2012, when her cellmate Esther Matthews was

unable to bring her around. The correctional staff were alerted and excused Esther so they

could apply the oxygen tank, which appeared to be faulty. Despite this, they refused to allow

Esther to continue mouth-to-mouth resuscitation. It was Esther’s determination to save Tracy

which prompted her to ignore their orders and proceed with CPR until the oxygen tank began

to function. The situation escalated quickly as she was not responding and consequently,

Tracy was administered an injection of adrenaline to ensure her survival; this particular

situation was recorded by the corrective staff.

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6. Drug use whilst in custody

i. What drug/s had Tracy been using or taking in prison?

ii. Could she have been placed back on a methadone or buprenorphine program in prison?

iii. Was Tracy allowed to participate in any drug and/or alcohol rehabilitation programs

during the 3 years and 9 months served, if not, why? (Was she prohibited as a sanction

after an incident between her and Marilyn Brown, drug and alcohol worker at

Silverwater?)

iv. Did Tracy get moved from Silverwater Correctional Centre to Dillwynia Correctional

Centre in order to have access to additional programs? If so had these commenced?

v. Should Tracy’s drug use have been more closely monitored?

vi. Should she have been tested when they witnessed her unusual behaviors? 7. Education: Time better spent

• Tracy was a strong advocate of education in prisons and computers in cells.

• She assumed a figurehead position amongst the other women prisoners at Dillwynia,

and she was looked up to by many of the other prisoners.

• She was elected to be a delegate of the Inmate Development Committee.

• Tracy talked about how there were no full-time positions for women in education at

Silverwater Correctional Complex (previously Mulawa); there is only a librarian and an

assistant.

• Tracy mentioned that there are computer classes as well as ones in art, pottery,

cooking and English as a second language, although access to computers is very

limited – there would often be two classes running at the same time with only one officer

so there could only be 15 prisoners at any one time from over 270 women held at

Silverwater.

• Tracy suggested that the education program needs two officers so as to maximize its

effectiveness.

• What could Tracy have achieved if she had have had adequate access to a computer in

her cell over the past 3 years 9 months?

• Tracy was taken out of Education classes for asking an “inappropriate question”

regarding a male officer’s behaviour, which coincided with when she had sanctions first

put on her in 2012.

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8. Opportunities Lost • Tracy wanted to get a business degree. She applied to the Department of Education

multiple times but was continuously rejected. Her mother, Sandra Kelly offered to pay

but she still was not given permission to do it.

• Three children are now motherless, Tracy saw her two sons regularly throughout the

last 3 years and 9 months in prison. Her sons must now grow up without their mother.

• Tracy’s parole officer from Dillwynia Correctional Centre had told her that she thought it

was possible to recommend Tracy for parole. Upon being released, Tracy was going to

live with her mother and/or with Jinx.

• Recently, her partner Jinx proposed (for the second time) to Tracy in prison – they were

going to work on their relationship upon Tracy’s release.

• Tracy would want questions to be asked of Corrective Services regarding whether the

correct policies and procedures had been followed given that she was obviously

affected by drugs when she was locked in her cell on the afternoon of Sunday 24

February 2013. Was it not obvious to prison staff and JH that she was heavily affected

by drugs? And if so, why was she not monitored and/or placed in a safe or dry cell?

DCS and JH had a duty of care to keep Tracy alive and safe.

9. Previous examples of avoidable deaths in custody: There is a long line of deaths in custody before Tracy, with stern criticism of Correctional Services and Justice Health. A few examples include Scott Simpson and Craig Behr, Michael Heatley. The Death of Mark Stephen Holcroft

• Death by heart attack in a prison van travelling from Bathurst to Mannus Correctional

Centre on 27 August 2009.

• Despite the other prisoners in the van banding on the inside of the van in attempt to get

the attention of the prison officers in the front, for a period of 20 to 45 minutes, the van

did not stop until it reached Mannus at which point Mr Holcroft was then already dead.

• Resulted in The Holcroft Inquest.

• The Coroner’s findings raise significant issues regarding NSW Corrective Services’

commitment to the welfare and human rights of prisoners.

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Although the death of Mark Holcroft occurred whilst he was being transported between

Correctional Centres by the NSW DCS – and the Inquest into his case raises issues mostly

relevant to the conditions of DCS transport vehicles, as well as the provision of adequate two-

way communication and adequate supervision in DCS transport vehicles. However, the

Holcroft Inquest raises many issues relevant to the death of Tracy Brannigan, regarding the

proper exercise of care by DCS officers in relation to the health and welfare of prisoners, and

the lack of supervision of at-risk prisoners. Both of these deaths in custody could have been

prevented had the prisoners been adequately monitored and had alert mechanisms been in

place.

Similarities to Tracy’s Case:

(i) Mr Holcroft reported to Justice Health nurses that he had chest pains a week before his

transfer. Tests were performed but the results were misread.

In Tracy’s case, despite the fact that the DCS was aware of her state of health, i.e. the fact

that she was visibly and undoubtedly affected by drugs leading up to her death on Monday

25 February, no action was taken in regards to this knowledge.

(ii) Expert evidence given at the Inquest indicated that his death was preventable because

if the tests were properly interpreted, he should have been immediately hospitalised,

and would have been treated successfully.

Despite Tracy having been subjected to target urine tests in the months leading up to her

death, DCS failed to test her in the five days leading up to her death despite her visibly

obvious state of being under the influence of drugs.

(iii) The coroner found that Mr Holcroft’s death was primarily the result of the failure of

Justice Health to provide him with proper care.

According to the Holcroft Inquest, further precautions should have been taken by the prisons to

ensure at risk prisoner’s were carefully monitored and could alert the prison guards for

assistance when required. It is apparent that the same can be said in Tracy’s case.

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10. DCS and JH Duty of care

The Royal Commission into Aboriginal Deaths in Custody (1987- 1991) recognised that when

a person is removed from society and deprived of their liberty, the responsibility of the state to

exercise a duty of care and prevent harm to that person is significantly increased.

Commissioner Elliott Johnston wrote in the Commission’s final report “that a custodian owes a

duty to a prisoner to take reasonable care for his or her safety. The existence of the duty of

care is fundamentally associated with the fact that, by definition, a person in custody has been

taken from his or her ordinary environment, cut off from normal sources of assistance…and

made dependent for all requirements upon the custodial authority.” Further, that “the duty of

care owed by custodians…extends to the provision of proper medical care, whether requested

by the prisoner or not.”

It is a well-established principle of law that custodial authorities (employees of the department)

have an obligation to prisoners whom it is reasonably foreseeable could injure others or

themselves. As such, it can be said that the death of Tracy Brannigan was primarily the result

of the Prison employees’ failure to intervene, when it was visibly obvious that Tracy was under

the influence of drugs, and their failure to monitor her state and provide her with proper care.

11. Could Tracy’s death have been prevented? DCS and JH failed to exercise proper duty of care at a number of pivotal points during Tracy’s

custody:

i. Failure to implement drug rehabilitation and/or treatment plan; Failure to recognise the

need for coordinated, ongoing and proactive management of Tracy Brannigan.

ii. Failure to keep adequate records and to exchange vital information between relevant

staff. Including records of Tracy’s prior overdose, also regarding her drug affected state

in the time leading up to her death.

iii. Inappropriate security classification and cell placement – despite being aware of Tracy

being under the influence of drugs (obvious by her being required to wear overalls, and

being supervised at the front and sides by prison guards, required to sit at the front of

the visits area under the surveillance cameras, not to mention her physical state during

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her last visit on Sunday 24th February) – she was placed in isolation in the ‘high needs’

area of the prison, as a sanction, and as a result died of a suspected overdose.

iv. No positive expression for her energy and time. Tracey was left with frustration and a

desire to lessen the pain.

12. Action Plan The question needs to be asked of DCS how this can be allowed to happen. Where are the

policies in place to prevent drug overdoses in prison? There is a need to ensure avoidable

tragedies such as Tracy’s death do not happen again.

Key Points:

i. DCS and JH must create a culture in which their employees respect the human rights of

prisoners. This should be reflected in open and accessible policies and protocols that

reflect their special responsibilities in holding them in their control away from their family

and community.

ii. Creation of a clearinghouse for deaths in custody, including direct prisoner and family

representatives and a Legal Center, to establish guidelines derived from previous

deaths and Coroners Reports.

iii. Review of the procedures and protocols in place for balancing the need for disciplinary

sanctions when prisoners misbehave, with the need to exercise proper care and

supervision, and offer adequate assistance to all prisoners, especially those showing

obvious signs of being at risk of health problems including drug use and/or overdose.

iv. Cessation of the use of isolation as a sanction in prison, especially in the case of at risk

prisoners. Also, review of the monitoring systems in place for at risk prisoners

(surveillance cameras etc.)

v. Investigation and review of Drug and Alcohol addiction programs and rehabilitation

Programs. In addition to a review of the success rates of drug intervention and

withdrawal programs.

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vi. Education: access to education with computers in cells is essential; education

stimulates the mind and encourages rehabilitation and hope for change in the future.

Greater empowerment and opportunities come with greater access to education and

study.

Contact Justice Action Trades Hall, Suite 204, 4 Goulburn St, ph: 612 9283 0123 fax: 612 9283 0112 Sydney NSW 2000, Australia email: ja@justiceaction.org.au PO Box 386, Broadway NSW 2007, Australia www.justiceaction.org.au