Long Bay Prison Hospital inmate Craig Behr was one such victim. Behr died less than two hours after being locked in a cell with inmate, Michael Heatley, who had told a psychologist just days earlier that he had been “experiencing homicidal urges for the past 18 months”.

Supreme Court Justice, Anthony Whealy, found Heatley guilty of manslaughter in November 2006, and called urgently for “[a]n independent and free-ranging inquiry … to answer the questions that the family of the deceased and the public legitimately ask to be answered; to explain why it was that a fellow inmate was placed in the offender’s cell in circumstances where he had made it only too plain that he was in the grip of homicidal urges”.

Noting the Supreme Court was not the forum to determine ultimate responsibility for failures in the system, he nonetheless observed: “I am satisfied that the placement of Mr Behr in the offender’s [Heatley’s] cell occurred as a consequence of both systemic and individual failures on the part of some prison officers to adhere to proper practices and procedures.”

His views were echoed some four years later by deputy state coroner, Malcolm MacPherson, who concluded the inquest into Behr’s death in December last year, almost seven years after the death. His written findings following the 16-month inquest are highly critical of the Department of Corrective Services, which submitted incomplete documentation, and of various corrective services officers, who had attempted to alter or conceal evidence, and whom he found had given unreliable, misleading and otherwise unconvincing testimony during the inquest.

Magistrate MacPherson offered a scathing account of “[t]he lack of action, the lack of follow up, the lack of seeking specific directions from superior officers” and “a near total lack of appropriate action by various correction officers” on the day of Behr’s death. The lethal chain of errors that culminated in Behr’s death began, he concluded, with senior correctional officers. Those in charge, he wrote, paid “insufficient regard” to the warnings of Danielle Matsuo, the forensic psychologist employed by Corrective Services to assess Heatley’s mental state. Matsuo’s assessment — that Heatley was a high risk to others and should not be permitted to share a cell with any other inmate — was made clear not only in her written report, but also by Matsuo herself, who personally warned senior officers of the risk.

Heatley told investigating police that he had pleaded with Corrective Services officers not to put Behr in his cell: “I didn’t want to kill him man, I didn’t even know him. I’m not schizo but I do have a mental problem. I’m homicidal, I’ve told them that for days. Then they tell me this morning that they’re putting this guy with me and I begged them not to but they said they were going to. I told them I’ll kill him but they just said ‘you’re full of shit’.”

Catriona McComish, a former senior assistant commissioner at Corrective Services NSW, says overcrowding in remand prisons could sometimes make it difficult to allocate appropriate accommodation to inmates, however it was possible that negligence or even malice also played a role.

“Many times it seemed like it was either, at best, a lack of attention and lack of care, lack of bothering, and at worse, something more malevolent because it would seem extraordinary, sometimes, the kind of pairings that had been made,” she said.

“It comes down to the kind of attitude that officers take. Of course there can be communication slip-ups or the file mightn’t have come through — all those kinds of things can happen –but if they were actually concerned, there would always be options and alternatives. You can always find out the information if you need to, really. If someone cared then, that’s what they’d do, so you’d just have to say, well, they obviously didn’t care enough.”

The murder of Craig Behr in 2004 was the third to occur in as many years as a result of inappropriate jail or cell placement.

In 2003, Lim Ward was stabbed to death at Emu Plains Correctional Centre in 2003, by a prisoner with a history of violence towards custodial officers and inmates, including an assault on another prisoner at the same prison the previous year.

In 2002 Andrew Parfitt was killed while in a safe cell at Silverwater Metropolitan Reception and Remand Centre, the day after he entered Corrective Services’ custody. Parfitt, a convicted p-edophile, was at his request being housed in the safe cell in protective custody, with the requirement of continuous clinical observation.

Scott Simpson, the man later found not guilty of Parfitt’s murder by reason of mental illness, had also requested to be placed on protection. He wrote on his application that he had “fear of them [Koori prisoners] killing me or me them if placed together”. He was identified as having a “serious mental illness” and his screening form noted that, at admission to the MRRC, Simpson had become “very aggressive towards another inmate and assaulted him without a cause. Can be violent.”

Simpson was brought into Andrew Parfitt’s cell at 6.08pm. During the fatal assault — which Corrective Services officers failed to notice despite CCTV cameras allowing round-the-clock surveillance of activity in the safe cell — Simpson punched and kicked Parfitt as he lay on the floor, then jumped on his head. By 6.24pm Parfitt was dead.

The issue of officers ignoring emergency calls was also raised at the 2009 inquest into the death of Ehalamreza Ahmadi. On the night of Ahmadi’s death, custodial officers took almost four hours to respond to the alarm activated by Ahmadi’s cellmate, who discovered Ahmadi hanging from a makeshift noose attached their cell window in the early hours of the morning.

The inquest revealed that prison staff had taped over the alarm speaker and turned the volume down as low as possible, having been directed to ignore the alarm by a senior manager who said he was not aware that the alarm had been installed or that his staff were expected to respond to it. This practice had been in place for three months before Ahmadi’s suicide in June 2008.

At Ahmadi’s inquest, officers told the court that alarm calls sometimes went unanswered because inmates often abused the alarm system with nuisance calls. Corrective Services officers at Behr’s inquest gave similar evidence, saying that on the day of Behr’s death, an inmate had been infuriating officers by continually activating the alarm in his cell for many hours before the killing, and that this contributed to their delayed response.

Coroners were unsympathetic in both cases. Deputy state coroner Hugh Dillon, who investigated Ahmadi’s death, said: “The evidence that alarms are abused on occasion by some prisoners is, frankly, unsurprising … [T]he scope of the Department of Corrective Service’s duty of care is not reduced by such misconduct and … the Department has ample powers under the Crimes (Administration of Sentences) Act 1999 and the Crimes (Administration of Sentences) Regulation 2008 to deal with any disciplinary offences committed by inmates without officers resorting to informal vindictiveness.”

He added: “[I]f such a culture or practice exists it places prisoners and perhaps officers in jeopardy and exposes the department to criticism and, conceivably, legal action.”

Officers ignoring inmates’ calls for help has contributed to at least four deaths in NSW prison custody since 2004.