Inquest into the Death of Iain Campbell BUCHANAN

Inquest into the Death of Iain Campbell BUCHANAN

Delivered on : 21 February 2024

Delivered at : Perth

Finding of : State Coroner Fogliani

Recommendations :Yes

Recommendation No. 1

That the Department of Justice develop clear and consistent training for prison officers in respect of the management of aggressive behaviour by prisoners, including how to respond to physical altercations between prisoners in accordance with governing legislation, policies, and procedure.

Recommendation No. 2

That the Department of Justice continues to take all necessary and practical steps directed towards investment in body worn cameras and improved CCTV coverage for high-risk areas of Hakea Prison including coverage of recreation areas within Hakea Prison.

Recommendation No. 3

That the Department of Justice and the Western Australia Police Force consult and consider pathways for the implementation of an integrated information sharing system that would allow Offender, Victim and Witness information populated in the Western Australia Police Force Incident Management System to be shared with the Department of Justice for the purpose of flagging any crossover between named Offenders, Victims and/or Witnesses in custody, and contemplated to be housed in the same prison, so that a risk assessment can be undertaken as to appropriate placement.

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 1 May 2019 Mr Iain Campbell Buchanan (Mr Buchanan) died at Royal Perth Hospital as a result of complications, including pneumonia, of traumatic brain injury.  He was 65 years old.

Immediately before death Mr Buchanan was a prisoner, serving his sentence at Hakea Prison.  He was admitted to Hakea Prison on 4 April 2019, transferred into unit 10 on 14 April 2019, assaulted by another prisoner (Prisoner CD) the next day, and he died in hospital two weeks later.

While Mr Buchanan was in the community, he had an altercation with a male person (Prisoner AB) that resulted in criminal damage charges being laid against Prisoner AB.  Mr Buchanan was recorded on the police computer system as a “witness” in respect of the charges against Prisoner AB (though there is no evidence that he gave police a witness statement in respect of the criminal damage charges).

At Hakea Prison, Prisoner AB spoke of his belief that Mr Buchanan had given police a statement implicating him in the criminal damage charges, including to his cellmate, Prisoner CD.  On 15 April 2019, shortly after an initial heated interaction in the recreation compound where Prisoner AB pushed Mr Buchanan to the chest (with both walking away), Prisoner AB returned to where Mr Buchanan was, with Prisoner CD, and prisoner CD assaulted Mr Buchanan by punching him in the face.  Mr Buchanan fell backwards and when his head hit the ground, he sustained the traumatic brain injury from when he subsequently died. 

The State Coroner considered the quality of Mr Buchanan’s supervision, treatment and care.  The State Coroner made no criticism of the supervision performed by the individual prison officers on 15 April 2019, but was satisfied that there was room for improvement in the Department of Justice’s training for prison officers and made a recommendation directed towards training in the management of aggressive behaviour. 

The State Coroner was satisfied that there was room for improvement by the Department of Justice, in that the prison infrastructure was not conducive to appropriate supervision due to there being blind spots obscuring part of the prison officers’ view of the prisoners in the recreation compound.  The State Coroner made a recommendation directed towards investment in body worn cameras and improved CCTV coverage for high-risk areas of Hakea Prison, including recreation areas.

The State Coroner was satisfied that with the benefit of hindsight, there could have been better access for the Department of Justice, to information held by the Western Australia Police Force reflecting upon the potential for animosity as between Mr Buchanan and Prisoner AB (whilst acknowledging that at the material time this access was not possible).  The State Coroner made a recommendation directed towards information sharing in respect of Offender and connected Victim and or Witness information, so that a risk assessment can be undertaken as to appropriate placement of prisoners.

The State Coroner was satisfied that the standard and quality of Mr Buchanan’s medical treatment and care at Hakea Prison was appropriate and noted the improvements in the Department of Justice’s procedures at Hakea Prison for calling an ambulance.  She found that the prospect of survival for Mr Buchanan, given the severity of his traumatic brain injury, was very small.

The State Coroner described Mr Buchanan’s death by unlawful homicide, in a prison setting, as a catastrophe.  She noted that while an absence of criticism may mean that minimum standards of acceptability have been met, if such deaths are to be avoided in future, there needs to be a commitment to continual improvement beyond a mere minimum standard of acceptability.

Catch Words : Death in Custody : Brain injury : Prisoner safety: Supervision, treatment and care : Training for prison officers : Management of Aggressive Behaviour : CCTV and Body Worn Cameras : Information Sharing: Unlawful Homicide


Last updated: 29-Feb-2024

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