Inquest into the Death of Brian John KEALY
Delivered on: 26 March 2026
Delivered at: Perth
Finding of: Deputy State Coroner Jenkin
Recommendations: Yes
Recommendation No. 1
In order to better manage prisoners and thereby enhance security at Hakea Prison, the Department of Justice should, without delay, take all necessary steps to ensure that Psychological Health Services (PHS) and prison mental health clinicians have reciprocal access to prisoner information stored in the EcHO computer system and the PHS module of the Total Offender Management Solutions system respectively.
Recommendation No. 2
The Department of Justice (the Department) should review the delivery of mental health and psychological health services within Hakea Prison in light of the recommendations made by Dr Adam Brett in his report dated 12 November 2025, which reviewed Brian’s care.
Specifically, the Department should:
- Form a project group with the Department of Health (DoH) to determine the feasibility of DoH assuming responsibility for prisoner health care (including primary, psychiatric, psychological care); and
- Whilst the discussions in paragraph (a) above are taking place, the Department should assess the appropriateness of adopting a truly multidisciplinary model of mental and psychological health care at Hakea Prison, led by a psychiatrist who would provide clear clinical governance, to enable clinicians to work collaboratively to develop appropriate management and treatment plans for prisoners requiring care.
Recommendation No. 3
To enhance the treatment and care provided to prisoners at Hakea, the Department of Justice (the Department) should take all necessary steps to ensure that all available medical, psychiatric and/or other reports and information (Information) relevant to a prisoner’s care and treatment are freely available to treating mental health and psychological clinicians. The Department should also identify any legislative, policy or other barriers preventing access to such Information, and take all available steps to remove such barriers.
Recommendation No. 4
The Department of Justice (the Department) should take all reasonable steps to ensure that the provisions of “EMF-DIR-022 Operational debriefing” are complied with.
In particular, in relation to critical incidents involving deaths in custody, the Department should ensure that wherever possible, personnel involved in the critical incident participate in immediate and formal debriefs, so that valuable insights from those officers can be captured and incorporated into any “lessons learned” process.
The Department should also ensure that lessons learned reports are disseminated to relevant staff, including those involved in the management and conduct of emergency response skills.
Recommendation No. 5
The Department of Justice (the Department) should conduct a review of the number of mental health and psychological health clinicians at Hakea Prison to determine whether these staffing levels are adequate. Meanwhile, the Department should redouble its recruiting efforts to fill currently vacant positions and should review salary and other benefits with a view to attracting appropriately qualified clinicians.
Orders/Rules: No
Suppression Order: N/A
Summary: Brian John Kealy (Brian) was 42-years of age when he hanged himself on 02 August 2024. At the time of his death, Brian was on remand at Hakea Prison (Hakea) having been charged with offences including in relation to serious criminal offences.
Brian had an extensive criminal history and was imprisoned on 15 occasions between 2004 and 2024. Brian also had a history of polysubstance use (including alcohol and methylamphetamine) and he had been admitted to psychiatric facilities on several occasions in relation to drug-induced psychosis, and/or ongoing depression and anxiety.
During his incarceration at Hakea, Brian was regularly seen by PHS counsellors, and that he was also reviewed by PMH clinicians on a number of occasions. At times when it was considered he was at risk of self-harm, Brian was managed on the At Risk Management System, and he was regularly monitored. During various risk assessments when he was being managed on ARMS, Brian consistently expressed thoughts and plans of self-harm to prison counsellors, and he repeatedly requested help from mental health staff to re-instate his olanzapine prescription.
There was a difference of opinion between prison counsellors and mental health staff about the basis for Brian’s repeated requests for olanzapine, and his self-reports about suicidality when his olanzapine dose was ceased and not reinstated. The Acting Deputy State Coroner found that because Brian’s psychological and mental health care fragmented and there were no regular multidisciplinary team meetings this difference of view was never resolved.
At about 1.00 pm on 2 August 2024, a prison officer went to Brian’s cell to conduct an ARMS observation. When the officer opened the cell’s observation hatch, they saw Brian hanging from the top bunk with a bedsheet around his neck. Prison officers cut Brian down and started CPR. Paramedics arrived at Hakea and took over resuscitation efforts, but Brian could not be revived and he was declared deceased at 1.40 pm.
However, the Acting Deputy State Coroner concluded that the standard of monitoring by the Officers while Josh was restrained in the prone position was poor. The Acting Deputy State Coroner was found there was no communication between the Officers as to who was monitoring Josh, and that one officer in particular (who was not involved in either applying handcuffs to Josh’s wrists or restraining his feet) should have been more vigilant while monitoring Josh and should have noticed that Josh had stopped breathing at an earlier stage.
The Acting Deputy State Coroner concluded that the supervision, general custodial management, and the treatment and care Brian received in relation to his physical health was adequate. However, the Acting Deputy State Coroner found that the standard of the care and treatment Brian received in relation to his mental health was poor. The Acting Deputy State Coroner made five recommendations aimed at improving the psychological and mental health care provided to prisoners at Hakea.
Catch Words: Death in Custody : Hanging : Fragmented Mental Health Care : Suicide
Last updated: 22 April 2026