The December 3 findings of a coronial inquest into the 2021 death in custody of Simon Mark Cartwright, paint a harrowing picture of the last days of a man suffering from serious mental and physical illness.

But while the State Coroner’s Court of New South Wales (NSW) found that Cartwright’s death was “preventable” and highlighted the “unacceptable care” he received at the Silverwater Metropolitan Remand and Reception Centre (MRRC) in Sydney, the report is ultimately a whitewash, holding no one responsible.

Cartwright died on September 19, 2021, one month after being remanded, awaiting sentence, to Silverwater prison for stalk/intimidate and trespass, assault and resisting arrest charges. He was found in a state of rigor mortis, indicating he had been dead for several hours.

Cartwright suffered from schizophrenia and bipolar disorder, as well as chronic peptic ulcer disease, which had likely infiltrated his liver at the time of his incarceration, according to the coroner’s report. None of these illnesses were picked up during his Reception Screening Assessment (RAS), although they had been documented in his file during an earlier incarceration at the same facility in January.

The coroner found Cartwright died from “undetected treatable natural causes while involuntarily detained as a mentally ill person within the general prison population while waiting 17 days for a bed in a mental health facility.” The immediate “natural cause” was septicaemia, a bacterial blood infection, resulting from his ulcers.

One of the expert witnesses consulted for the inquest, Dr Christopher Vickers, a gastroenterologist, stated that if Cartwright had been given Pantoprazole even as late as 4-5 days before his death, he would likely have survived the infection that killed him.

Cartwright’s condition was further exacerbated by the denial of his access to water, crucial for diluting stomach acids that increase the severity of gastric ulcers. Two days before his death, the tap in Cartwright’s cell was turned off. Prison guards made no record of this action, nor is there any record that he was subsequently provided with bottled water.

The court was told the water was shut off because Cartwright had flooded his cell by leaving the tap running. Correctional officers, and medical staff from Justice Health, which is responsible for monitoring the health of prisoners, “did not appear to know or understand that he was a mentally ill person requiring hospitalisation.”

In the final 48 hours of his life, Cartwright begged for water through the intercom system 18 times and made multiple requests for food, blankets and to see a nurse, all of which were denied. On two other occasions he reported he was having trouble breathing. The inquest showed footage of him buckled over clutching his stomach, falling over backwards and sideways, and shuffling around like an old man.

Underscoring the inhumane conditions, in one case, a guard responded to Cartwright’s pleas for water: “Yeah, this is really entertaining actually,” and “Yeah, keep buzzing up, actually this is keeping me entertained.”

At one point, Cartwright was so desperate he offered to give the guards money he had in the bank if they helped him. The coroner found that the guards used denial of water for a “correctional or punitive purpose,” which he merely concluded was “inappropriate.”

A record of Cartwright’s history of mental illness and drug abuse illustrates the tragic consequences of the erosion of dedicated facilities for mental health patients, and the reliance as a result on overstretched hospitals and inadequately funded community facilities.

Cartwright’s “happy childhood” changed when at 17, according to his family, he was introduced to cannabis. In 2008, he was diagnosed with schizophrenia and in 2013, bipolar disorder. His medical records show he was aware of and understood his diagnosis and fought for many years to keep his symptoms under control, through regular contact with medical and mental health professionals, who treated him with anti-psychotic medication.

The coroner cited notes from his regular psychologist that “Simon was engaged with treatment, had insight into his mental illness, was polite, and was honest about his drug misuse.”

In June 2020, Cartwright’s regular GP came to believe he was abusing drugs. Concerned that he was showing signs of aggression and intimidation in pursuit of opioid and benzodiazepine prescriptions, the doctor decided to terminate their relationship. 

The next month, a psychiatrist at Shellharbour Hospital changed Cartwright’s longstanding diagnosis of schizophrenia and bipolar to “a substance-induced behavioural disturbance complicated by narcissistic personality features.”

This resulted in the discontinuance of the anti-psychotic medications Cartwright had been taking for the past decade. His regular psychologist disagreed with and warned against this, concerned that Cartwright would become a problem for the police and end up in prison if his “psychiatric condition was not properly managed.”

Cartwright’s mental health deteriorated, while his gastric symptoms led to hospitalisation every month for the rest of 2020.

In November, he attended Wollongong Hospital for an upper gastric bleed, which necessitated a blood transfusion. He repeatedly requested anti-psychotics, complaining of ongoing “chatter” and that he was “sick in the head,” but was refused due to his changed diagnosis.

By the end of December 2020, Cartwright’s aggressive pursuit of risperidone (an anti-psychotic drug) and diazepam (Valium) led his regular GP to permanently stop seeing him, for “personal safety reasons.”

Cartwright was arrested in January 2021 for lighting a fire in a neighbour’s apartment and was incarcerated at MRRC, Silverwater. He was immediately put on a Risk Intervention Team (RIT) management plan, as he was threatening self-harm.

At this point, both his gastric ulcer and his history of schizophrenia and bipolar were noted and documented by MRRC staff. He was given Pantoprazole to reduce stomach acid secretion. A Justice Health nurse advised he should be treated under section s33 of the Mental Health Act and designated a mentally ill person under that legislation. He was then transferred to Cumberland Hospital, where he received appropriate treatment, made what appeared to be full recovery a month later, and was released from detention.

In July 2021, police took Cartwright to the mental health unit at Wollongong Hospital for making 35 “nonsensical” calls to emergency services. Again, his diagnosis of schizophrenia and bipolar was denied and he was discharged.

In early August he was taken again by police to Shellharbour Hospital after he was found “running through traffic, yelling and head-butting himself against a bus stop.” He was incarcerated for the last time at MRRC on August 21, 2021. This time, instead of getting the highest monitoring available under the RIT management plan based on assessments that he was a threat to himself and others, he died without anyone watching him, without basic medical treatment or even water to drink and with his pleas for help repeatedly ignored.

The death in custody of Simon Cartwright is just one grim example of the consequences of a much broader trend.

According to the Australian Institute of Health and Welfare, more than half of Australian prisoners surveyed in 2022 had been told by a doctor, psychiatrist, psychologist or nurse that they had a mental illness or behavioural problem at some point in their lives.

Mental illness has increasingly become a matter left to the police and the prison system, as a direct result of decades of cuts by Labor and Liberal-National governments to funding for mental health services. In NSW, this began with the 1983 Richmond Report, commissioned by the Wran Labor government, which called for mental institutions across the states to be shuttered, forcing many people with mental illnesses into dilapidated boarding houses, homelessness or the prison system.

The treatment of the mentally ill and other vulnerable members of society is a warning to the working class more generally. Under capitalism, every aspect of working-class health and lives is subordinated to the profit interests of the corporate and financial elite.

While Labor governments around the country continue to slash funding for health, education and other social necessities, they are pumping obscene sums of money into the military and the police, under conditions of growing opposition to war and the deepening social crisis. This underscores the need for the working class to fight for a political alternative, socialism, in which society’s vast resources are no longer used to further enrich the wealthy few, but to provide a high standard of living, including free, high-quality mental and physical health care, for all.