Inquest into the Death of Tim Alan LOOKER
Inquest into the Death of Tim Alan LOOKER
Delivered on : 8 July 2025
Delivered at : Perth
Finding of : Coroner Urquhart
Recommendations : Yes
Recommendation No.1
To improve the care and treatment of prisoners with previously diagnosed ADHD, those prisoners who were prescribed and using a short-acting stimulant (such as dexamphetamine) in the community at the time of their imprisonment, be given the option of having prescribed a long-acting stimulant (such as lisdexamphetamine) as an alternative medication for the treatment of their ADHD.
Recommendation No.2
To assist the treatment of prisoners with previously diagnosed mental health issues, the Department of Health and the State Forensic Mental Health Service permit “read-only” access to PSOLIS by prison medical officers.
Recommendation No. 3
To assist the health care and treatment of prisoners, the Department introduces a prompt on its EcHO system for staff to follow up a request for a prisoner’s medical information that has not been provided within a reasonable time after that request.
Recommendation No. 4
In order to better manage vulnerable prisoners and thereby enhance security, the Department should take immediate steps to ensure all cells in Unit 2 are either three-point or fully ligature minimised as quickly as possible.
Recommendation No. 5
In order to enhance the care of prisoners, the Department adopts across the entire prison estate the recent change made by BRP to its “Fortnightly Security Checks” form so that prison officers are reminded of the importance to identify potential ligature anchor points in cells.
Orders/Rules : No
Suppression Order : N/A
Summary : On 3 October 2023, Tim Alan Looker (hereafter referred to as Tim at his family’s request) was found hanging in his cell at Bunbury Regional Prison (BRP). He was unresponsive, and despite prompt resuscitative efforts by prison officers and medical staff, he could not be revived. His cause of death was ligature compression of the neck (hanging). Tim was 29 years old.
At the time of his death, Tim was a sentenced prisoner and was in the care of the CEO of the Department of Justice (the Department). As he was a person in care, his death was subject to a mandatory inquest.
Tim commenced his term of imprisonment on 26 June 2023. At the time, he was regularly taking two prescribed medications. Tim had been diagnosed with ADHD as a child and was prescribed dexamphetamine. In 2022, he was diagnosed with Type 2 diabetes and prescribed metformin. During the time Tim was imprisoned (99 days), he was not prescribed either of these medications.
Although Tim was referred to BRP’s Psychological Health Services (PHS) by a prison officer who had observed his depressed appearance, Tim declined an offer to engage with PHS after a staff member made contact with him in September 2023.
On 1 October 2023, prison officers witnessed a verbal altercation between Tim and another prisoner. A decision was made to separate Tim from this prisoner and he was placed in A Wing of Unit 2 in a two-person cell by himself.
On 3 October 2023, prisoners in Unit 2 were locked in their cells from about 11.45 am to 1.00 pm whilst prison staff had their lunch break. When Tim’s cell door was locked, he was asked by a prison officer if he was okay and Tim responded that he was. When the cells were unlocked, that was done without sighting the prisoners inside their cells.
At about 1.20 pm, another prisoner was escorted to Tim’s cell where he was going to be relocated. When he walked into the cell, the prisoner observed Tim hanging from a torn bed sheet that had been attached to a bolt protruding from a window frame of the cell.
The Coroner was generally satisfied that the Department’s supervision, treatment and care of Tim was appropriate. However, missed opportunities were identified that involved the lack of any follow up to the request of Tim’s psychiatrist to provide information regarding his ADHD, not having Tim initially assessed by the prison doctor within 90 days of his imprisonment, and not having the unauthorised bolt in Tim’s cell removed. The Coroner was satisfied this bolt had been there for some time.
No criticism was made by the Coroner that Tim was not prescribed dexamphetamine or metformin during his imprisonment at BRP. As dexamphetamine is a short-acting stimulant that may be trafficked within the prison setting, it was Department policy at the time not to administer it to prisoners with ADHD. As to his diabetes, Tim had not raised with any health service provider at BRP that he was diagnosed with this condition and prescribed medication to treat it. Consequently, he was not prescribed metformin during his imprisonment at BRP.
The Coroner made five recommendations, including one that prisoners with previously diagnosed ADHD and who are prescribed a short-acting stimulant in the community be given the option of having their ADHD treated by a long-acting stimulant during their imprisonment.
Catch Words : Mandatory Inquest : Death in Custody : Sentenced Prisoner : ADHD : Mental Health : Supervision, Treatment and Care : Recommendations : Suicide
Last updated: 28 July 2025