For the second time in six months, a coroner calls for ceiling fans at Darwin's prison be to fitted with a device that prevents them from being used in suicide attempts.
A coronial inquest into the death of Mr Bonson, 31, whose full name cannot be used for cultural reasons, found he died by suicide at Darwin Correctional Centre in August 2016.
His death came nine months after the suicides of inmate Roy Melbourne, 81, and a female prisoner, all by similar methods.
The inquest heard on the day of his death, Mr Bonson made a number of phone calls to his family in Maningrida and as the afternoon went on, he was unsettled.
Security footage shows his cell mate finding him dead early the next morning and calling for help.
Coroner Greg Cavanagh said there was no evidence to indicate to prison officers that Mr Bonson was at risk of self-harming.
"In fact neither did he give his family the impression that he was thinking of self-harming," the coroner said.
Load-sensing device developed, Government says
In July 2017, coroner Greg Cavanagh criticised the cost-cutting decision to install ceiling fans, saying it "beggar's belief" a modern-day prison would give prisoners access to such a "classic hanging point".
More than six months later, in his findings into Mr Bonson's death, Mr Cavanagh urged Northern Territory Corrections to ensure the risk posed by fans at Darwin prison be mitigated by the installation of a load-sensing device.
He noted that it was not a suggestion that they be removed but they be installed in a way so they cannot hold the weight of a person and used as hanging points.
While the project had yet to be completed by the Northern Territory Government, it told the inquest that obtaining a load-sensing mechanism had been difficult, although one had been developed and was expected to be finalised in a matter of days.
Since the fans were removed from the single occupancy cells in December 2017 and replaced with desk fans, a number of prisoners had complained about them not working as well, the inquest heard.
The coroner also noted Mr Bonson had been transferred to a new block that day without the reason being recorded by corrections.
Mr Cavanagh recommended the correctional services commissioner ensure the reasons for transfers of prisoners be recorded.
