By Mark Russell and Nick Toscano
A coroner has weighed into Victoria's prison crisis, warning inmates are increasingly at risk of harm.
Coroner Peter White linked ''avoidable'' deaths in custody to staff shortages at remand centres, prisons and police cells, while delivering his findings on the death of a mentally ill prisoner who hanged himself in 2010. He warned that the system of dealing with mentally ill inmates at Melbourne Assessment Prison was stretched and more funding was needed to minimise the threat of self-harm or suicide.
The prison's overworked nurses were reviewing inmates' mental health without adequate levels of training and support from busy senior clinicians, he said.
Mr White spoke after a veteran criminal lawyer warned that riots and deaths in custody were more likely while the ailing prison system struggled with cell shortages. Former Law Institute of Victoria criminal law chairman Rob Melasecca said it was ''a matter of time before riots eventuate and there are potential deaths in custody''.
Armed robber Adam Omerovic was found dead in his cell at the Melbourne Assessment Prison in 2010.
Delivering his findings on Friday, Mr White said Mr Omerovic had been arrested over six armed robberies in Melbourne's inner east. He was assessed and found to be mentally unfit to be interviewed.
Mr Omerovic, who had a past history of mental illness, was sent to prison when remanded on two charges of armed robbery, two counts of assault and nine other charges.
A routine psychiatric assessment by a nurse at the prison determined he was a significant risk of suicide and it was recommended he be placed under observation. Despite this, he was transferred to the general prison after staff noted he did not seem depressed.
The coroner said cellmate Leon Cook gave evidence that over the next few days Mr Omerovic spoke extensively and lucidly to him about the breakdown of his relationship with his wife and talked of ways of killing himself in the cell.
Mr Cook said Mr Omerovic told him he had used syringes or knives during the armed robberies and was expecting to be sentenced to a 10-year jail term.
Mr Omerovic was found dead five days after arriving at the prison. Mr White found he had been denied an in-depth examination by a psychiatrist and not given any appropriate medication when he was ''pushed out into the general prison population before that course was safe''.
''In so finding, I am mindful of the difficulties faced by Forensicare (responsible for providing adult forensic mental health services in Victoria) together with Corrections Victoria around the administration of psychiatric health care duties at MAP, at the time of Mr Omerovic's death,'' he said.
But Mr White said there had been an immediate need to place Mr Omerovic in a safe cell environment and this was not done.