Coroner's Court of Western Australia

Inquest into the Death of Tania Marie HODGKINSON

Inquest into the Death of Tania Marie HODGKINSON

Delivered on :5 February 2020

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes


I endorse the recommendation of the Inspector of Custodial Services that a new Visits Centre be built at Bandyup Women’s Prison to facilitate:

  • Increased capacity and privacy,
  • Separate spaces for children’s play area, search and change rooms facilities,
  • Appropriate CCTV and staff levels, and
  • Incorporated official visits.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was a 48 year old Aboriginal woman who died on 23 March 2017 while being held in custody at Bandyup Women’s Prison. The deceased had been remanded in custody since 30 December 2016 in relation to violence related offences which arose out of a family dispute.

The inquest focused mainly on the care, supervision and support provided to the deceased prior to her death and to establish whether her death could have been predicted and prevented.

On arrival at Bandyup Women’s Prison the deceased was assessed by a clinical nurse. She was recorded as having no history of medical or psychiatric conditions. However, the deceased was experiencing heroin withdrawal symptoms and she verbalised self-harm intent. She also spoke of her grief at losing her partner from a heroin overdose. The deceased was initially placed into the Crisis Care unit and placed on a high level of the At-Risk Management System. Her withdrawal symptoms were managed with standard medical treatment and she was kept under close observations. She was also referred to the prison Alcohol and Substance Team and the Prison Counselling Service. After a few days she was moved out of the CCU into the general prison population.

On the morning of 23 March 2017 the deceased attended a counselling session, during which she denied having any currents thoughts or plan to harm herself. She did mention wanting to move to a different prison with her cellmate, and the counsellor was following up this request. However, before that could be done, the deceased was found hanging inside her cell. She had used a torn sheet as a ligature. Despite CPR being performed and the attendance of medical staff and ambulance officers, she could not be revived.

During the inquest hearing concerns were raised in respect to the visits room at Bandyup Prison, and the possible effect it may have had on the deceased receiving visits and having contact with her family. The Coroner noted a recent report from the Inspector of Custodial Services who found the Bandyup Visits Centre unfit for purpose and did not meet the needs of officers, prisoners or visitors. The Coroner made a recommendation relating to improving and upgrading the facility.

The Coroner was satisfied that the deceased’s care in prison was overall reasonable and appropriate. The Coroner concluded the deceased’s decision to take her life appears to have been impulsive.

Catch Words : Grief Associated with Recent Death : Drug Dependent : Financial Difficulties While Incarcerated : Adequate Facilities in Women’s Prisons : Suicide.

Last updated: 9-Jul-2020

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