Experts raise alarm about 'safe cells' after multiple NSW prison deaths

The last time Daniel Turnbull appeared before a magistrate, she promised to "sort out everything and get you in some treatment".

Nine days later, he collapsed on the floor of a bare, concrete cell.

Daniel, who lived with schizophrenia, had been put in the cell under 24-hour monitoring for his own safety.

Warning: Readers are advised this article includes the name and images of Indigenous people who have died, used with family permission. It also references suicide.

Left alone for days, he'd spent much of his time pacing in circles, in between taking great gulps of water from the bubbler in his cell.

On his final day Daniel had grown wobbly on his feet, had vomited and become delirious.

Finally, in a daze, he had fallen backwards, hit his head on the wall and slumped to the floor.

For months, no-one knew how Daniel had died.

It was only when a lawyer for the coroner's office was watching the CCTV of Daniel's last day that she noticed something strange.

Daniel had drunk 237 cups of water in a single day.

He'd developed a condition called polydipsia — a life-threatening complication of schizophrenia, often driven by a person's delusions, whereby they cannot stop drinking water.

Two years later, coroner Erin Kennedy said she had one question to resolve.

How had Daniel's "continual and excessive" water drinking gone unnoticed when he was under 24-hour CCTV surveillance and awaiting psychiatric review?

The ABC can reveal Daniel was one of several NSW prisoners to die in recent years after being put in a monitored isolation cell, often due to fears for their own safety.

It has experts sounding the alarm about the risks of these cells, where isolation can have a catastrophic impact on health and where vulnerable prisoners are left to the supervision of guards with little to no mental health training.

Sensory deprivation 'a form of torture'

Rebecca Ferreira remembers her brother Daniel as a warm and affectionate child, always happiest outdoors.

As he grew older, he would jump on a train just to see where it would take him, sometimes finding a place to stay overnight and returning the next day with tales of what he'd been up to.

He loved to give his sister all-enveloping hugs.

"He was very warm and loving when he wasn't sick," Rebecca said.

As a teenager, Daniel began hearing voices.

He turned to alcohol to self-medicate, and when he drank, he could be violent. Previous contact with the law had been dealt with under mental health laws.

By the time he was 35, he'd had more than 40 psychiatric admissions.

Daniel died 97 days after entering custody on charges including assault.

That he spent his final days alone in a stark concrete cell, with very little human contact, is a particular source of sadness for Rebecca.

"The devastation is that that's my brother, and he needs help and he's not being helped."

Prisons use "safe cells" to reduce the risk of suicide or self-harm, ensuring at-risk inmates are kept under close watch in cells where hanging points are removed or "minimised".

In Daniel's case, a mental health nurse was worried about him after he confessed to hearing "derogatory" voices and expressed "paranoia" other inmates wanted to hurt him.

She checked his records, in line with policy, and saw he'd missed a number of doses of his antipsychotic meds in the last fortnight.

Daniel wasn't under the care of a Risk Intervention Team, which usually decides where to house an at-risk inmate, but the nurse knew she wanted him kept safe until she could get him in to see a psychiatrist in three days' time.

So she recommended he be sent to a camera cell in the Multi Purpose Unit.

It meant he'd be watched by a security guard who monitored the CCTV of all 14 cells.

But it also meant he would be held in isolation at a time when his mental health was already precarious.

By the time Daniel collapsed he had been in the cell for more than 50 hours.

On his second day, he drank up to 70 cups of water.

On his third day, it was about 40 litres, and it accelerated as the day went on.

Shortly before he fell, he drank about 50 cups of water in just half an hour.

Daniel had shown no signs of polydipsia before entering custody.

It's a poorly understood condition, but his coronial inquest would hear that this period in an isolation cell may have helped bring it on.

"When an individual is in a state of psychosis without medical attention and locked in a cell with very few things to distract them, this could play a role in its development," forensic psychiatrist Danny O'Sullivan said.

The ABC has previously revealed Daniel was one of three prisoners with schizophrenia to die from polydipsia in less than two years.

In March 2021, 35-year-old Worimi and Iama man Trevor Samuel died of the condition, which he was known to have, while at Long Bay's prison hospital.

In December 2022 — two months after Daniel — 47-year-old Aboriginal woman Tammy Shipley died at Silverwater women's prison after drinking up to 20 litres of water in a day.

She had spent 10 nights alone in a safe cell, with very little human interaction.

Forensic psychiatrist Olav Nielssen also told Tammy's inquest her isolation likely played a role in her polydipsia.

"I think it was probably a combination of the course of her psychotic illness and the sensory deprivation, because if she'd been communicating with people or watching television or out and about, she may not have just kept going back and forth to the tap," he told the ABC.

More harm than good

Forensic psychiatrist Kerri Eagle says the risks of isolation are well documented.

They include panic, emotional disturbances, cognitive impairment, sleep deprivation, intrusive thoughts, paranoia, delirium and dissociation.

She told the ABC that many inmates will avoid revealing suicidal thoughts for fear of ending up in a safe cell.

"Your clothes [may be] removed, the lights remain on 24 hours a day … and you have no contact with anyone else generally for extended periods of time," she said.

"It's a form of punishment. It's a form of torture recognised by the United Nations and identified by the Mandela Rules as inappropriate for someone with a mental health impairment."

Dr Eagle is a clinical director for the prison health agency Justice Health, but spoke to the ABC in her capacity as a private practitioner.

She told the coroner investigating Wiradjuri man Bailey Mackander's 2019 death that the use of safe cells to manage suicide risk is "counter therapeutic, disempowering and distressing for prisoners, and adds no clinical value".

It only increases the risk of self-harm or desperate behaviours, she said.

"If [prisoners] have a major mental illness, they need to be given appropriate psychiatric care for that illness, and that needs to be done in a therapeutic environment," Dr Eagle told the ABC.

"[That's] not in an isolation cell where a person [can be] stripped down and then left alone and just watched, which is not going to change that person's mental state or mood or level of safety in any meaningful way."

Dr Eagle said these cells carry a further risk: vulnerable inmates are monitored by correctional officers who have no clinical training.

"Of course, a corrections officer can't possibly understand what is needed for a physical health or mental health condition," she said.

Monitoring inmates via CCTV, she added, was "inherently unreliable".

She wants the assessment and management of at-risk inmates brought under the sole remit of Justice Health, an arm of the New South Wales Health department.

"It is not appropriate for Corrective Services to be managing those health conditions because their goals are security and law enforcement," she said.

"Health needs to be managed by people who are concerned with the wellbeing of individual patients."

A Corrective Services spokesperson told the ABC it "adheres to strict legislative and regulatory frameworks to safely, securely and humanely manage people within its facilities".

The spokesperson said it delivers mental health care in "a co-ordinated inter-agency response" with Justice Health through multidisciplinary teams.

A Justice Health spokesperson said it was committed to advising and working with Corrective Services to support "the most appropriate placement of people in custody who are mentally unwell".

'Something really wrong with this guy'

The week before Daniel Turnbull died, he appeared at Katoomba Magistrates Court for his charges to be heard.

It was the first time he had a lawyer, having refused representation and declined to seek bail at his earlier hearing.

The magistrate asked his lawyer for a psychiatric report so she could deal with his charges under mental health laws.

She told Daniel that when the case resumed in six weeks, she would "sort out everything" and get him into treatment.

But seven days later, he was put in the isolation cell.

On his third night, Daniel collapsed at 6:47pm.

A guard in the monitor room spotted him on the floor 13 minutes later, sending another guard to check on him while he watched back the camera tape.

The guard who checked on Daniel told the coroner he wasn't allowed to enter the cell without another officer present, even in emergencies.

He said he'd spoken to Daniel, who'd told him he was OK and not hurt, that he was just "lying down".

When the guard returned for the third time at 7:20pm, Daniel was having a seizure.

By the time the nurse arrived 11 minutes later, Daniel was lying face down and had turned blue, with vomit pooling from his mouth.

At that point, guards called for an ambulance.

An autopsy later showed the excess water had caused Daniel's sodium levels to drop and his brain to swell, a process known as hyponatraemia.

Michael O'Leary, an intensive care specialist, reviewed the CCTV vision of Daniel's final hours for the inquest.

Dr O'Leary told the coroner the vision of Daniel's collapse was "so concerning that medical attention should have been summoned for immediately", even though by then — because polydipsia requires much earlier intervention — it was likely too late.

"If you rewound the video and watched it and saw how he ended up on the floor, you would immediately say, 'That is really bad. There's something really wrong with this guy,'" Dr O'Leary told the ABC.

The guards watching Daniel said they had no training in mental health and no knowledge that drinking excessive amounts of water could be fatal.

Deputy State Coroner Erin Kennedy found Daniel's hyponatraemia could have been prevented if he had been closely monitored, but those monitoring him would need to have known excessive water intake can be dangerous.

The signs of hyponatraemia were subtle, she said, and water drinking was a "benign" activity the guards may not have thought unusual, as they hadn't been trained in "atypical behaviours" to look out for.

Ironically, she said, had Daniel stayed in the general prison population rather than a safe cell, a cellmate might have noticed his excessive water drinking and raised the alarm.

Corrective Services NSW (CSNSW) did not answer the ABC's question about whether an ambulance should have been called sooner.

A spokesperson said CSNSW had made changes to better identify and respond to people in distress and ensure collaboration between custodial staff and health services.

This included updating its policies to identify excessive water intake as a risk, as the coroner recommended.

"Corrective Services NSW extends its sympathies to those grieving the loss of a loved one who has died in custody," the spokesperson said.

These days Rebecca holds on to the memories of who her brother was when he was well.

"There was only love, you know?" she said.

"Whenever I turned up to visit, he'd say, 'Hi Becky' and always come in for a hug.

"He'd always ask how I am. He'd always ask what's been happening.

"And I miss my brother because the true essence of him was love."

Inquests into NSW prison deaths following isolation

W (2015)

While suffering untreated paranoid psychosis and being held alone in segregation, W "deteriorated to the point where he was overwhelmed by his delusion and his fear and chose to suicide as a relief from his torment", the coroner found.

David Wotherspoon (2017)

David, an Aboriginal man, attempted suicide in a safe cell and died nine days later in hospital. The coroner found the responsibilities of the officer monitoring the camera were "unduly burdensome".

Sony William Tran-Bui (2018)

Sony was put in a safe cell with a health form instructing guards he had paranoia and needed to be watched, but neither guard read the form. He died from a ruptured ulcer, with the coroner finding it difficult to understand how guards didn't respond to his "obvious distress".

Junior Fenika (2018)

Doctors told the coroner Junior's time in segregation "precipitated, amplified and perpetuated his mental illness [due to the] absence of human contact and sensory deprivation". The coroner found his death was preventable had guards responded to his knock-up calls.

Bailey Mackander (2021)

Bailey, a Wiradjuri man, died after making a sudden bid for escape after his mental health deteriorated in a safe cell. The coroner found he was left in the cell "without any psychological or social support [or] diversionary activities involving human interaction".

Gavin Ellis (2022)

Gavin died by suicide after being held in a safe cell, where he was stripped to his underwear and left for four days "with absolutely no psychiatric or therapeutic support".

Simon Cartwright (2024)

Simon died of a treatable ulcer after spending almost a month in a safe cell, where guards repeatedly ignored his calls for help. The coroner found that CSNSW "is not and should not be placed in a position to care for a mentally ill person".

Alfonso Ceniccola (2025)

The guards supervising Alfonso in his safe cell failed to read his health form, failed to perform hourly checks and left him, slumped and unattended, for 105 minutes. The coroner found they displayed "a most unfeeling attitude towards a vulnerable inmate".

How we investigated this story

The Indigenous Affairs Team used AI to scour hundreds of coronial findings into NSW deaths in prison custody.

We downloaded the open-source findings via links collated by the University of Queensland Deaths in Custody project.

We then cross-checked these against our own scrape of the New South Wales coroner's website.

We loaded the findings from January 2015 to September 2026 into an AI program and asked it to identify patterns among the deaths of people with schizophrenia or other mental illness.

We then read and fact-checked every inquest finding that identified deficiencies in their care or supervision.