SINGAPORE: A man sentenced to life imprisonment in 2004 for abduction climbed up a railing in Changi Prison's psychiatric housing unit during yard time and released his grip, falling one floor below and dying of a head injury.
The coroner ruled his death a deliberate act of suicide on Tuesday (Dec 22), noting that the prison has taken steps to prevent recurrences and is reviewing other possible safety measures including a sensor system to detect anyone near the railings.
An internal review by the Singapore Prison Service (SPS) found no negligence on the part of any prison officers, and SPS is reviewing its infrastructure design, the court heard.
Mr Chua Ser Lien was pronounced dead on the morning of Jul 8 this year after being seen climbing a set of railings from the second floor to the fourth floor.
He released his grip and fell backwards, hitting the back of his neck. He received immediate attention from officers at the scene and paramedics who arrived 20 minutes later, but he could not be resuscitated.
The court heard that Mr Chua, who has two children with his ex-wife, was imprisoned in Changi Prison's Cluster A since 2004, where he was remanded after being charged with kidnapping for a ransom.
He was transferred to the psychiatric housing unit in 2018 after his pre-existing bipolar symptoms grew worse.
Prison officers in this unit - the sole housing unit that deals with inmates with psychiatric issues or mental disorders - have attended courses to help them in dealing with the inmates.
Mr Chua was assessed to be non-suicidal.
On the morning of his death, officers dispensed medication to the inmates through metal gates before allowing them out of their cells for the scheduled hour of television time in the TV room.
However, Mr Chua - who was noted to be reclusive - had never joined them for TV time and would be allowed out of his cell to roam the day room. He had done this for months without any issue.
Closed-circuit television footage showed Mr Chua walking up the stairs from the third floor to the fourth floor, where he began climbing up railings that had bars across them.
He climbed sideways from the bars, using them as steps, until he was on the fourth level. By this time, officers spotted him and rushed to the scene and called out to him, but Mr Chua released his grip and fell backwards.
He landed on the back of his head at the foot of the stairs on the third floor. Rescue efforts failed and he was declared dead at 10.15am that day.
HIS MENTAL HEALTH RECORDS
His only available medical record was from the Institute of Mental Health, where he was remanded in early 2004. He was diagnosed with bipolar disorder.
Before this, he had been a managing director in a cleaning company, but his erratic behaviour began to manifest when he visited a university for a meeting and offered to donate a million dollars, before racking up S$600,000 of gambling debts.
He later reported being depressed and began drinking heavily. After his conviction and sentence, his wife filed for divorce in order to apply for a rental flat, but still considered him her husband and visited him with their two children.
She had been concerned that he had a mental illness since 2002, when he began to manifest hallucinations, telling her that the kitchen was hell and the living room was heaven.
She referred him to a private hospital for treatment and suspected he had schizophrenia, bipolar disorder and depression.
In the months before his death, his ex-wife noticed that Mr Chua had become more aggressive towards her during her visits and she felt his medication did little to help him. She last visited him in November 2019, before speaking to him over the phone in June this year.
However, she saw no signs of suicidal inclinations in her ex-husband. The other prison officers and Mr Chua's cellmate also did not notice any such signs, the court heard.
After Mr Chua's death, SPS instructed that no inmate would be allowed to remain alone outside their cells. High-risk inmates will now be warded in the complex's medical centre.
The prison is also reviewing its infrastructure design and is considering a sensor system that would be triggered whenever anyone tries to move close to the railings.
SPS said it is also studying the feasibility of installing additional railings at the stairs to deter inmates from scaling from the stairs to the railings.
The coroner noted that the railings were originally meant to prevent prisoners from falling off the second floor, but unfortunately facilitated Mr Chua's climb instead.
The railings are likely to be replaced with ones that cannot be gripped or held onto, the court heard.
The coroner noted that Mr Chua had been receiving appropriate medical treatment during his incarceration, and that the prison wardens and medical staff had responded promptly.
He conveyed his condolences to Mr Chua's family.
In a statement on Tuesday night, SPS said it noted the findings of the coroner's inquiry and that it is "committed to ensuring the safe and secure custody of inmates".
"Mr Chua's death, which has been ruled a deliberate act of suicide by the coroner, is an unfortunate incident," said SPS.
It added that SPS officers reached out Mr Chua's family after his death to extend assistance and extended their condolences to his family.
Where to get help: Samaritans of Singapore operates a 24-hour hotline at 1800 221 4444, or you can email firstname.lastname@example.org. If someone you know is at immediate risk, call 24-hour emergency medical services.