A coronial inquest into the death of a prisoner who took his own life while under CCTV monitoring has found his death may have been prevented if he had been more closely observed.
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However the State Coroner also found the prisoner could not have been easily watched due to the poor-quality camera footage, and suggested maximum-security staff should be rotated more frequently through the unit's control room to combat fatigue.
Dale Sloan was 24 in October 2013 when he hanged himself in the exercise yard of the maximum security unit of Brisbane Correctional Centre.
He was found about 15 minutes later. Prison officers and paramedics attempted to revive him at the scene, but he died in hospital four days later, on October 6.
While there were two CCTV cameras monitoring the exercise yard where Sloan died, only one was shown on the centre's control room computer screens. The control room had four computer screens, with images from 27 security cameras displayed across three.
The correctional officer operating the control room at the time of Sloan's death, James Finn, said he noted Sloan in the exercise yard but did not see anything unusual.
"I didn't see anything suspicious or out of place as I remember thinking he must be rolling a cigarette and just standing quietly," he said, focusing his attention instead on three other prisoners who were arguing.
When police investigators recreated events to test Mr Finn's testimony, they found "even with the benefit of hindsight" it would have been hard to see precisely what Sloan had been doing in the exercise yard.
Sloan had an "extensive criminal history" dating to 2006, and he was remanded in custody on September 13 in 2013 for allegedly setting his former partner's home on fire and a number of other offences.
Just one day after he was remanded, he climbed onto the roof of the correctional centre with another inmate where they damaged airconditioning units and security cameras.
When they finally left the roof, the men both received six months in the maximum security unit as punishment.
Sloan was referred to the prison mental health service where he was noted to have a history of contemplating suicide, but he denied such thoughts at the time of his incarceration.
He was placed on a formal observation regime when first taken to maximum security, and over the few weeks there the regime was regularly assessed and reduced until it was ceased on September 27.
The coroner agreed with the findings of the police investigation.
"Those observations could not be carried out easily because of the limited quality of the single camera angle in the exercise yard that was available to be viewed by the correctional officer," the state coroner said.
The first aid was also found to be of a "suitably high standard", and the coroner said it was "highly doubtful" anything could have been done by the time Sloan was found to prevent his death.
With the security camera system due to be updated in 2017 or 2018, the coroner said he was satisfied a similar death would be unlikely to happen again.
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