Coroner's Court of Western Australia

Inquest into the Death of Callum MITCHELL

Inquest into the Death of Callum MITCHELL

Delivered on : 22 July 2022

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

The Department of Justice (DOJ) should conduct a review to determine whether the resources and facilities currently available to staff at Hakea Prison (Hakea) to manage prisoners with complex behavioural needs are adequate.  The review should consider the feasibility of establishing a behaviour management unit at Hakea, staffed by specialist mental health practitioners and custodial staff, to enable prisoners with complex behavioural needs to be appropriately managed.

Recommendation No. 2

As a matter of urgency DOJ should undertake remedial work at Hakea Prison to ensure that all cells on Unit 1 are fully ligature minimised.

Recommendation No. 3

DOJ should create an alert within the Total Offender Management System to prompt prison officers whenever a prisoner’s scheduled observations under the At Risk Management System are not entered into the supervision log, and should consider the circumstances in which it would be appropriate to activate such alerts.

Recommendation No. 4

DOJ should explore the feasibility of introducing regular refresher training for the Gatekeeper program for all prison officers, and should also investigate the feasibility of providing senior prison officers with additional training in the effective management of prisoners with personality disorders and common mental health conditions.

Orders/Rules : No

Suppression Order : Yes

On the basis that it would be contrary to the public interest, I make an Order under section 49(1)(b) of the Coroners Act 1996 that there be no reporting or publication of the name of any prisoner on Unit 1.  Any prisoner is to be referred to as “Prisoner [Initial]”.

Summary : Mr Callum Mitchell (Callum) was 26-years of age when he died on 21 April 2019 from ligature compression of the neck at Hakea Prison (Hakea).  At the request of his family, the deceased was referred to as “Callum”.

Calum had an extensive criminal history and spent a considerable part of his adult life in custody.  On 1 February 2019, Callum was sentenced to a term of 15 months’ imprisonment for attempted armed robbery, backdated to 2 September 2018, the date of his arrest.

Callum had a very troubled childhood and was thought to satisfy the criteria for borderline personality disorder and antisocial personality disorder.  He was also diagnosed with attention deficit disorder and had history of seizures, although it was unclear whether these had a physical or psychological cause.

Callum had a history of polysubstance use and his periods of imprisonment were characterised by repeated incidents of self-harm, many of which were potentially fatal.  During his last period of incarceration, Callum was involved in 55 self-harm and/or behavioural incidents between January 2019 and April 2019.  These incidents included attempts to hang himself, making cuts in his arms and legs with broken glass and pieces of ceramic and setting fire to his cell.

Although Callum was seen by nursing staff and psychologists at various times, because he had not been diagnosed with a major mental illness, he did not meet the criteria for specialist psychiatric care.  Instead, Callum was managed on the At Risk Management System (ARMS) and placed in a safe cell at various times.

Custodial staff struggled to cope with Callum’s increasingly serious self-harming behaviour and in March 2019, the Acting Superintendent of Hakea reached out to the Department’s Specialised Psychological Service (SPS) for assistance.  After a further follow up and an email, the SPS forwarded a behaviour management plan from 2017, when Callum had been incarcerated at Casuarina.

Following a serious self-harm incident on 11 April 2029, Callum was placed on ARMS and moved to a safe cell.  On 17 April 2019, his mental state appeared to have settled and he his ARMS observations were reduced and he was returned to a cell in Unit 1, the management unit at Hakea.

After lunch on 21 April 2019, Callum attended the medical centre at Hakea to receive prescribed medication.  Instead of returning directly to his cell, he instead went to a restricted area where he spoke to a prisoner from another unit.  When he was eventually discovered shortly after 2.00 pm, he was returned to his cell and subjected to a strip-search which found nothing.  During the search, Callum appeared to be in good spirits and he was locked in his cell for the remainder of the afternoon.

At about 4.20 pm, an officer unlocked Callum’s cell to serve him dinner and found him slumped against the left-hand side wall of the cell, next to the sink.  Callum was unresponsive and had white strips of material around his neck that were tied to the sink’s single tap.  The ligature was removed and offciers started CPR.  Ambulance officers arrived and took over resuscitation efforts, but Callum could not be revived.

The coroner concluded that the supervision, treatment and care provided to Callum during his incarceration was of a lower standard than it might have been, because in the period leading up to his death, custodial staff were unable to access specialised psychological support to help them to manage Callum’s extremely challenging and confronting self-harming behaviours.

The coroner made four recommendations aimed at improving the management of prisoners with complex behavioural needs.

Catch Words : Death in Custody : Hanging : Management of complex behaviours: Tiered care model of treatment : Suicide

Last updated: 11-Aug-2022

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