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Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Inquest Findings

Home →Inquest Findings→Inquest Findings 2026→Tollett, Kyen Steven

Inquest into the Death of Kyen Steven TOLLETT

Delivered on: 22 July 2026

Delivered at: Perth

Finding of: Brendyn Dean Nelson

Recommendations: Yes

Orders/Rules: No

Suppression Order: No

Recommendation No 1: The Department amend the At-Risk Management System manual to expressly reference the capacity for risk alerts to be raised in the Total Offender Management Solution system identifying known, significant stressors as a ‘risk to self’ for any individual prisoner.

Recommendation No 2: The Department disseminate information to staff reminding them of the function, and encouraging any staff who are, or become, aware of a known, significant stressor in relation to an individual prisoner to identify the same by way of an individualised risk to self alert within the TOMS system.

Summary:

Mr Kyen Steven Tollett was a remand prisoner when he died on 10 October 2024 after hanging himself in his cell at Casuarina Prison. Mr Tollett was transported to Fiona Stanley Hospital following extensive resuscitation efforts but could not be revived. He died from ligature compression of the neck and the Coroner found his death occurred by way of suicide.

The Coroner determined that Mr Tollett received generally appropriate treatment, supervision and mental health care while in custody, including regular psychological and psychiatric support. Issues concerning the accessibility of critical suicide risk information to operational staff were considered, and recommendations were made to improve the recording and visibility of individual risk factors and significant personal stressors within custodial information systems.

Catch Words: Death in Custody, Suicide


Last updated: 4 August 2026

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