Coroner's Court of Western Australia

Inquest into the Death of Suzzanne Denise DAVIS

Inquest into the Death of Suzzanne Denise DAVIS

Delivered on : 28 Mar 24

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

Recommendation No. 1

In order to better manage prisoners and thereby enhance security at Melaleuca Women’s Prison (Melaleuca) the Department should, as a matter of the utmost urgency, undertake remedial work at Melaleuca to ensure that all cells are fully ligature minimised.

Recommendation No. 2

The Department should undertake an immediate audit of bunkbeds in all cells at Melaleuca Prison to ensure that these structures are fully ligature minimised.

Recommendation No. 3

The Department should remind custodial staff (by way of a Commissioner’s Notice or other appropriate method) that prisoners are not to be asked or permitted to assist with an emergency response to another prisoner, except in exceptional circumstances.

Recommendation No. 4

The Department should consider ways in which dates of interest (DOI) for prisoners who are not being managed on the At Risk Management System (but who have nevertheless been identified as requiring additional support) can be flagged, so as to ensure that these prisoners can be followed up by staff before and after the DOI.

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 (other than the deceased) housed at Melaleuca Prison on 13 August 2020.  Any such prisoner is to be referred to as “Prisoner [Initial]”.

Summary : Suzzanne Denise Davis (Ms Davis) was 47-years of age when she died on 13 August 2020 from ligature compression of the neck.  At the time of her death, Ms Davis was a remand prisoner at Melaleuca Women’s Prison (Melaleuca) and therefore in the custody of the Chief Executive Officer of the Department of Justice (the Department

In the days before her death, several members of staff, and a fellow inmate (Prisoner T) who was a life-long friend of Ms Davis noted that her mental state had changed.  Although none of these people were of the view that Ms Davis was at any acute risk of self-harm, she seemed confused and more withdrawn hat usual.  An appointment was made for Ms Davis to be reviewed by a psychiatrist on 13 August 2020, but she did not attend the appointment, and in a brief court appearance by video link that day, she was remanded in custody for a further period.

At about 1.55 pm, Prisoner T alerted prison officers to the fact that Ms Davis was in her cell and was not responding to knocks on her cell door or shouts.  Three officers attended and when they unlocked the cell door, they found Ms Davis hanging with a bedsheet around her neck that was tied to a wooden bunkbed fitting within the cell.

Prisoner T helped a prison officer hold Ms Davis’ body up as another officer cut Ms Davis down and started chest compressions.  Prisoner T was then asked if she would like to assist by proving rescue breaths for Ms Davis, which she did.  The recovery team arrived a short time later and assisted with CPR, until ambulance officers arrived and took over resuscitation efforts.  Despite the combined efforts of Prisoner T, prison staff, and ambulance officers, Ms Davis could not be revived and she was declared deceased at 2.27 pm on 13 August 2020.

The coroner was satisfied that in relation to her physical health, whilst incarcerated Ms Davis received a level of care that was commensurate with that available in the general community.  The coroner was also satisfied that with the exception of the fact that Ms Davis was placed in a cell that was not fully ligature-minimised, Ms Davis received an adequate level of care and supervision whilst in custody.

However, the coroner also found that there were a number of missed opportunities where the management of Ms Davis’ mental health could have been improved, and the coroner therefore concluded that the mental health care Ms Davis received whilst she was incarcerated was inadequate.

The coroner made four recommendations.

Catch Words : Death in custody : Death by hanging : Ligature minimisation : Suicide


Last updated: 16-Apr-2024

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