Coroner's Court of Western Australia

Inquest into the 5 Deaths in Casuarina Prison who are Mervyn Kenneth Douglas BELL and Bevan Stanley CAMERON and Brian Robert HONEYWOOD and JS (Name Subject to Suppression Order) and Aubrey Anthony Shannon WALLAM

Delivered on :22 May 2019

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation 1
The Department should take urgent steps to recruit additional Prison Counselling Service (PCS) and mental health staff for Casuarina Prison and more broadly, should consider the appropriate level of PCS and mental health staff for prisons across the State.

Recommendation 2
The Department should increase the number of three point and fully ligature-minimised cells available at Casuarina Prison without delay. Priority should be given to those cells routinely used to house vulnerable prisoners (e.g.: the orientation cells in unit 5). In addition to increasing the number of ligature-minimised cells at Casuarina Prison, the Department should review whether the light fitting covers currently used in all cells at Casuarina Prison (and which are regarded as suitable for use in ligature-minimised cells) are fit for purpose.

Recommendation 3
In order to better manage prisoners and thereby enhance security at Casuarina Prison, the Department should, without delay, take all necessary steps to ensure that PCS and Prison Health Service staff have reciprocal access to prisoner information stored in the EcHO computer system and the PCS module of the Total Offender Management Solutions system respectively.

Recommendation 4
The Department should consider introducing a “triage” system into prisons where all prisoners who have a known history of self-harm and/or suicide attempts are reviewed by a mental health professional within 24 hours of being received into prison. Consideration should be given to the use of video-conferencing facilities for regional prisons where mental health staff are unavailable.

Recommendation 5
The Department should consult with an expert in the field of trauma informed custodial care (TICC) to determine a process for incorporating the principles of TICC into its management of prisoners at Casuarina Prison.

Recommendation 6
The Department should consult with an expert in the field of mental health with a view to providing training to all staff on the features of personality disorders and common mental disorders and strategies to more effectively manage prisoners with these conditions.

Recommendation 7
The Department should consider further enhancing its Gatekeeper training program to ensure that it is primarily focussed on risk in the custodial setting. Consideration should also be given to including additional guidance for relevant custodial staff (e.g.: reception officers) on conducting self-harm and suicide risk assessments. Gatekeeper refresher training should be conducted for all staff on a regular basis.

Recommendation 8
The Department should consider amending Policy Directive 36 – Communication so that where practicable, there is a positive obligation on custodial staff to advise a prisoner when changes are made to that prisoner’s Prison Telephone System account.

Orders/Rules : N/A

Suppression Order : N/A

Summary : At the time of all their respective deaths, the five deceased persons were prisoners in the custody of the Chief Executive Officer of the Department of Corrective Services, as it was then was.

Pursuant to a direction by the State Coroner on 25 February 2019, all five deaths were investigated at one inquest. That inquest focused on the supervision, treatment and care provided to each of the deceased persons while they were prisoners, as well as the circumstances of their respective deaths.

The Coroner found that that each of the deceased persons had died at Casuarina Prison and that the cause of death in each case was suicide. The Coroner heard evidence about the management of at risk prisoners, some of the risk factors impacting on prisoner management and the strategies and tools employed to address those factors.

The Coroner made eight recommendations relating to improving prisoner welfare and enhancing the security of Casuarina Prison.

Catch Words : Deaths in Custody : Mental Health Issues : Gatekeeper and Mental Health : Training : Prisoner Risk Assessment : Ligature Minimisation : Use of Technology : Suicide

Last updated: 16-Oct-2019

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