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An 18-year-old mother killed herself in a Melbourne prison yard just five days after being moved out of youth detention. Her body was not discovered for almost two hours, a coroner’s court has heard.

Tarsha Golightly was on remand – she was an unsentenced prisoner yet to be found guilty of any offence – when she died on 27 July at the Dame Phyllis Frost Centre (DPFC), in Melbourne’s west.

The coroner’s court heard on Friday that details of whether she had applied for bail would form part of a mandatory inquest into her death.

The fact that corrections officers took almost two hours to discover her body – and after fellow prisoners raised the alarm – will also be examined. The prison yard was covered by CCTV cameras, Friday’s hearing heard.

No details were heard in the court about what charges Golightly faced, nor the reasons for her relocation from the Parkville youth justice centre to women’s prison.

But bail laws described by the Victorian government as the “toughest in Australia” came into effect only weeks before her arrest and detention at the Parkville youth justice precinct on 4 May.

Coroner Simon McGregor told Golightly’s parents, who were watching the hearing, that he understood it would be a sad and difficult day for them.

“We recognise the ripple effect of people dying in unexpected circumstances,” he said.

“Understanding properly why they died in this unexpected way, in the very least, gives some clarity to all the people affected by that death.

“That information is also used to improve the planning for the state of Victoria.”

‘Allow them to do their work’

Counsel assisting the coroner, Amanda Burnnard, said that a focus of the inquest would be ensuring the risk of self-harm in Parkville and DPFC was reduced.

“None of us will lose sight of the fact that Tarsha was only 18 years old, and she was the mother of a very young child,” she said.

Burnnard said that there were seven potential “avenues of inquiry” at the early stage of the investigation, including Golightly’s circumstances before she was remanded, the circumstances of her remand, including whether she made a bail application, her treatment and the conditions of her detention at Parkville, including the health and support services provided to her, and why she was transferred to DPFC.

Her treatment at DPFC, including whether she was subject to any lockdowns – which have increasingly been used to manage staff shortages – and the circumstances in which her death occurred will also be investigated.

Burnnard told the court that Golightly was let out of her cell in the Dawson unit about 7.46am on 27 July. She was carrying a laundry bag with a sheet concealed inside.

She then climbed a water tank in the yard shortly before her death, the court heard.

Fellow prisoners found her about 9.41am, and alerted prison officers.

“Tarsha’s movements from her cell to the yard and the discovery of her body were all captured on closed-circuit television,” Burnnard said.

During a search of Golightly’s cell after her death, police found numerous handwritten notes with suicidal thoughts, as well as a knot that appeared to be fabricated from a piece of towel.

McGregor said external investigations could mean the inquest took longer to complete, but could mean the process was more thorough.

The court heard the department of justice; Forensicare, the state’s provider of forensic mental health care services; and Western Health, which provides healthcare to the DPFC; had all started independent investigations.

“The coroner doesn’t have to wait for those investigations, but if they look like they’re going to be useful … often it’s beneficial to allow them to do their work,” McGregor said.

“Often when there’s a parallel investigation, in my experience, it can be a slower process … but it’s worth it to get a thorough result.”

Burnnard said other evidence was currently being collected, including details on Golightly’s history in the justice system, and records on other deaths by suicide at DPFC over the past 12 months.

There have been at least 13 deaths in Victorian prisons in the past year, but none appear to have been recorded in the women’s prison.

• In Australia, the crisis support service Lifeline is 13 11 14. In the UK and Ireland, Samaritans can be contacted on freephone 116 123. In the US, you can call or text the 988 Suicide & Crisis Lifeline at 988 or chat at 988lifeline.org. Other international helplines can be found at befrienders.org