Prison guards using pepper spray on an incarcerated Indigenous woman who was self-harming was "inappropriate" and posed "unnecessary physical and mental harm", a report has found.
The ACT Custodial Inspector, who monitors the territory's adult and youth prisons, has recommended the territory's adult prison, the Alexander Maconochie Centre, ban the use of pepper or capsicum spray for similar incidents in a new report.
The inspector concluded that the Indigenous woman had been confined for 28 days in a "grossly disproportionate" and "inherently harmful" punishment before the incident, and the lack of information provided to staff could have resulted in serious injury.
"While the use of [capsicum] spray to respond to a detained person who is self-harming is not explicitly proscribed by policy or training materials, this review finds it should be... use of [capsicum] spray in this situation could further contribute to respiratory distress, in addition to the traumatic impact of being sprayed," the report read.
"Relevant ACT Corrective Services policy and training material on the use of chemical agents do not allign [sic] with human rights based practice as they do not appropriately consider the physical and psychological impact of oleoresin capsicum (OC) spray on someone who is engaged in self harming behaviour."
The report found the woman had been experiencing acute mental distress in the weeks before the incident in July 2025, including engaging in self harm. After being denied access to NAIDOC celebrations, she climbed onto a roof in protest, and was disciplined through placement in separate confinement for 28 days and losing privileges.
On the day of the incident, her request to attend an Aboriginal art program was refused, and soon after she attempted to harm herself, the report said.
Correctional officers responded promptly but did not call a health staff member and were not able to convince the woman to stop self-harming. They deployed capsicum spray and restrained her. She fell and briefly lost consciousness.
The inspector found there was no medical assessment before she was walked to the Crisis Support Unit area of the prison, where she was "decontaminated" and strip-searched before being placed in a cell that had just been vacated by a man. The review concluded that the lack of medical attention before the transfer posed a high risk of serious injury - and that it was a "near miss scenario" where physical injury could have been serious.
Despite the ACT Supreme Court finding the circumstances of a strip search on entry to the Crisis Support Unit unlawful in 2025, the woman was subject to it without reasonable grounds.
Up to 19 officers responded to the incident, which the inspector found was not consistent with ACT Corrective Services suicide prevention framework.
Important information about how to best support someone recently facing mental health crisis was not available to corrections officers, the report found, and recommended stronger engagement between correctional and health services.
The review also highlighted broader systemic issues affecting Aboriginal women in custody.
"While the inspector identified no direct racist behaviour, the cumulative effect of policies, practices and key decisions contributed to harm. This included, in the lead up to this incident, a 'grossly disproportionate' discipline penalty that included 28 days in isolation, reducing the detained woman's access to culture and kin at a time when she was experiencing mental health difficulties," the report read.
"Opportunities for culturally appropriate input at key decision points were missed, particularly when she transitioned from crisis care to the mainstream area of the prison. The inspector said this incident highlighted how prison systems can have a disproportionately harsh impact on Aboriginal and Torres Strait Islander women in custody, and more must be done to address deficiencies identified."
ACT Custodial Inspector Rebecca Minty said people in custody who were in distress and not at immediate risk to others needed an approach that focused on support.
"Using [capsicum] spray on someone who is self-harming and not posing a threat to others is inappropriate and should not happen," she said.
"Corrections staff did act quickly to intervene which was important, but the approach taken prioritised control over care. That is not consistent with a trauma informed response.
"For Aboriginal and Torres Strait Islander People in detention, connection to culture and kin is not an optional extra. Limiting access to culturally significant activities can have real impacts on wellbeing."
Ms Minty's review also renewed calls for guards to wear body cameras, as recommended in a 2025 review of the prison.
