Canberra’s criminal-justice system is fortunate to have an active Custodial Inspector, who tends to what might be termed the back end of the system: what happens to people after their conviction at Court.
This is when the media generally have no further interest in the court matters they pursued so closely. Same for the lawyers, who got their fees and can do no more. Sadly, it is sometimes the case that family and friends and other supports desert those sentenced to prison as well.
With that isolation heaped on top of the fact of their physical removal from the community, it is no wonder that incarcerated people (especially First Nations people) are especially vulnerable, making it so important that those charged with their care – in a human-rights jurisdiction such as ours – perform to the highest standards.
Sadly, that is not always the case.
This week, the ACT Custodial Inspector has found that gaps in care, communication and culturally informed decision-making contributed to a detained Aboriginal woman being sprayed with Oleoresin Capsicum (OC), or pepper spray, in response to her self-harming at the Alexander Maconchie Centre (AMC).
The Inspector’s review makes 11 findings and 4 recommendations. These focus on improving therapeutic responses to self-harm, ensuring health and corrections staff have the right information and work together, and ensuring cultural support is available at the right time and in the right way.
The woman had been experiencing acute mental distress in the weeks before the incident in July 2025. After being denied access to National Aboriginal and Islander Day Observance Committee celebrations, she climbed on to a roof in protest. The subsequent disciplinary breach resulted in her being placed in separate confinement for 28 days and losing privileges. On the day of the incident, her request to attend an Aboriginal art program was refused, and soon after she attempted to harm herself by placing a ligature around her neck.
Correctional officers responded promptly but were not able to convince her to cease self-harming. They deployed OC spray, removed the ligature and restrained her. She fell and briefly lost consciousness. There was no medical assessment before she was walked to the Crisis Support Unit (CSU) area of the prison where she was decontaminated and strip-searched before being placed in a cell that had just been vacated by a male. The review found that the lack of medical attention before the transfer posed a high risk of serious injury – and that it was a “near miss” scenario where physical injury could have been serious.
The review found that the use of OC spray in this situation posed unnecessary physical and mental harm on a woman self-harming, and posing no threat to others. The review recommends the jail ban the use of OC spray in these circumstances.
Important information about how to best support someone recently facing mental health crisis was not available to Corrections Officers. The report recommends stronger engagement between correctional and health services, to improve support when people move in and out of crisis care.
The review highlights broader systemic issues affecting Aboriginal women in custody. While the Inspector identified no direct racist behaviour, the cumulative effect of policies, practices and key decisions contributed to harm. This included, in the lead-up to this incident, a “grossly disproportionate” discipline penalty that included 28 days in isolation, reducing the detained woman’s access to culture and kin at a time when she was experiencing mental-health difficulties. Opportunities for culturally appropriate input at key decision points were missed, particularly when she transitioned from crisis care to the mainstream area of the prison. The Inspector said this incident highlighted how prison systems can have a disproportionately harsh impact on Aboriginal and Torres Strait Islander women in custody, and more must be done to address deficiencies identified.
The Inspector, Rebecca Minty, said, “People in custody who are in distress and not at immediate risk to others need an approach that focuses on support. Using OC spray on someone who is self‑harming and not posing a threat to others is inappropriate and should not happen.
“Corrections staff did act quickly to intervene which was important, but the approach taken prioritised control over care. That is not consistent with a trauma‑informed response.”
“For Aboriginal and Torres Strait Islander People in detention, connection to culture and kin is not an optional extra. Limiting access to culturally significant activities can have real impacts on wellbeing.”