Recommendations prompted by the suicide of a mentally ill prisoner in Westgate will not be made public sparking concerns over transparency.

Coroner Khamisi Tokunbo, who chaired the inquest last October into Lorenzo Robinson's death, told the jury he would file a report to the authorities with recommendations for preventing similar cases in future.

He has now done so, but asked if Mr. Tokunbo would be publishing the report, Coroner's officer Lyndon Raynor replied that he would not.

"The Coroner has ruled there is no legal requirement to release his recommendations to the public," he explained.

Both Saul Froomkin QC, the lawyer for the victim's mother, and Michael Dunkley, the Shadow Minister for Public Safety, expressed concern over the news.

And Scott Jable, the tourist Mr. Robinson stabbed and almost killed prompting his incarceration in Westgate said he could not understand why the recommendations needed to be kept private.

Senator Dunkley said: "The inquest was held in public, it's only fitting that any recommendations fall into the public domain as well. Accountability and transparency are very important."

Mr. Robinson was sent to Westgate indefinitely after being acquitted on grounds of insanity of attempting to stab Mr. Jable to death on Front Street in 2002. Experts said during his trial in 2004 that he was highly dangerous and required long-term detention and treatment in a secure forensic psychiatric facility, which Bermuda does not have.

Mr. Robinson obtained a ruling from Chief Justice Richard Ground four months before his suicide that his condition required him to be treated in such a unit, and that a designated "hospital cell" he was being kept in at Westgate was no such thing.

The Chief Justice asked for Mr. Robinson's care to be reconsidered, including the possibility of sending him overseas. However, he remained in Westgate, locked in a punishment cell for 23-and-a-half hours per day, until he took his own life on July 13, 2008.

He was not on suicide watch which meant he would have 15-minute checks and no access to bedclothes despite having made multiple prior attempts on his own life in Westgate.

The jury in the inquest also heard evidence that Mr. Robinson may have been bullied and put in fear of his life by other inmates and prison officers, although this was strenuously denied by the individuals in question.

Mr. Froomkin raised concerns over a policy that meant the officers on duty did not have access to cell keys in the segregation section at night. He also questioned whether Mr. Robinson's life could have been saved if access had been gained to his cell more quickly after he failed to respond to knocks.

Yesterday Mr. Froomkin said: "Having seen the recommendations, I wholeheartedly support them. They would be very useful in the public domain it might help prevent similar unfortunate circumstances occurring again in future."

He declined to share his copy of the Coroner's recommendations with this newspaper. He explained he was unable to do so because his client, Mr. Robinson's mother Dedona Grant, does not want him to. However, he commented: "I think it would certainly be helpful to the community as whole if the Coroner's views were made public because nowadays the jury can't make any recommendations. In the old days they could make recommendations and those were public."

Prior to a change in the law in 2000, an inquest jury could make recommendations publicly. Now, the rules allow a Coroner to announce at the inquest that they will report the matter in writing to the person or authority who may have power to take action to prevent similar fatalities. They make no mention of whether the Coroner has to make his report public.

However, Coroner Juan Wolffe has recently made recommendations public in the cases of Scott Michael Kozma, who died in a collision with a Police truck, and mentally-ill Shandal Richardson, who hanged himself at the Mid Atlantic Wellness Institute.

In both cases, the recommendations aimed to prevent similar fatalities in future.

Mr. Robinson's victim, Mr. Jable, said of the Coroner's decision to keep his recommendations in the case private: "On one side, I cannot see why the information contained in the report needs to be kept private. Certainly, if there are items that would compromise security at the prison, those should not be made available for public consumption. Or if some content could be deemed disturbing to Mr. Robinson's family or to any of the employees at Westgate, these, likewise do not need to be made available. But otherwise, what is to be gained by withholding the report?

"However, if Mr. Robinson's family and Westgate officials have indeed each received a copy of the recommendations, at least those most concerned have been notified and are able to deal with the information as they see fit. Since the real purpose of this inquest was to ensure that such a tragedy would be avoided in the future, one hopes that those at Westgate who are privy to the information will take it upon themselves to treat it with due respect and act accordingly."

Asked for a copy of the Robinson recommendations, Commissioner of Corrections Lt. Col. Lamb replied: "I am certain that I do not have the liberty to offer a copy of the report to any person external to our department."

However, he commented: "We have received the Coroner's report and are analysing it with a view to implementing those recommendations that will enhance our operations and management of inmates. In fact, the report reinforces the measures that we implemented even before the inquest commenced."

He stated at the conclusion of the inquest that changes had been made to the segregation unit to protect prisoners from harming themselves, and there was increased access to psychiatric services. However, Bermuda still lacks a forensic psychiatric unit for the criminally insane.

Sen. Dunkley noted: "Perception is very important in the community, and if things continue to occur without being addressed, the perception could be we are not doing enough to rectify the major challenges we face."

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