Tracy Brannigan’s Avoidable Death in Custody

Tracy Brannigan’s avoidable death in custody marks the loss of a loved one and must force change in the prison system. She was owed a duty of care but rather than accepting responsibility, they isolated her in a cell away from her family and support. Their callous indifference caused her death. Download Report and Action Plan

Update:Media Release Friday 3rd May 2013, Justice Action calls for a public inquiry into avoidable deaths in custody, and launches the Tracy Brannigan Action Plan.

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.

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 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 and/or her previous overdoses?
v. Why was Tracy not allowed to pursue her education?
vi. What duty of care did DCSand 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 re-married 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.

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 that 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.

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 the first instance she was sanctioned in 2012.

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 Michael Heatley, Scott Simpson and Craig Behr.

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.

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 – 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 25February, 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 prisoners 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.

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 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.

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.

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