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Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Government of Western Australia State Coat of Arms
Coroner's Court of Western Australia

Inquest Findings

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Inquest into the Death of Ashley James BROPHO

Inquest into the Death of Ashley James BROPHO

Delivered on : 4 December 2025

Delivered at : Perth

Finding of : Coroner Nelson

Recommendations :

  1. As a matter of urgency, the Department of Justice ensure the installation of closed-circuit cameras in any unit wings, unit dayrooms, commons areas and recreation yards within Units 6 and 7 at Hakea Prison.
  2. The need for compliance with ‘Commissioner’s Operating Policy and Procedure 10.2 - Daily Prison Routine and Population Counts’ and any applicable Standing Order be reinforced by:
  1. distribution of a Commissioner’s Broadcast (or similar) to all prison officers requiring compliance, notwithstanding any existing, historical practice; and
  2. the Department of Justice providing refresher training to prison officers.
  1. Clause 5.3.3 of ‘Commissioner’s Operating Policy and Procedure 10.2 - Daily Prison Routine and Population Counts’ be amended to insert an additional step to the procedures to be followed at lock-up, requiring the Unit Manager to sign the Occurrence Book stating that the general health and well-being visual check of all prisoners has been undertaken.
  2. ‘Commissioner’s Operating Policy and Procedure 4.10 – Protection Prisoners’ be amended:
  1. to reflect the ability for an ad-hoc review of a prisoner’s protection status outside the 6-month review; and
  2. to include a requirement (at cl 4.2.3) for the PMDT to consider ‘the likelihood of any risk the prisoner the subject of the assessment poses to the safety of another prisoner or class of prisoner within a protection unit’,

with necessary amendments to all related Standing Orders.

  1. The Department of Justice consider whether COPP 4.10 should also be amended to expressly require consideration of the maintenance of a prisoner’s protection status when the prisoner is transferred between prisons.
  2. The Department of Justice create a capacity in the Total Offender Management Solution for the placement of an alert on a prisoner which clearly indicates that the prison poses a risk to the health and safety of a specified cohort of prisoners (separate from the existing capacity to raise an alert identifying a risk of harm by one identified prisoner to another identified prisoner).
  3. The Department of Justice prioritise the creation of the group contemplated by Action 5.1 in the Lessons Learned Report, such group to be expressly responsible for the movements of high-risk prisoners who have been involved in serious incidences of violence within the prison system resulting in serious harm or death.

Orders/Rules : N/A

Suppression Orders :

  1. On the basis it would be contrary to the public interest, the Court makes an order under section 49(1)(b) of the Coroners Act 1996 (WA) that there be no reporting or publication of:
  1. the name of any prisoner (other than Mr Evan Martin) housed at Casuarina Prison in December 2020; or
  2. the name of any prisoner (other than the deceased or Mr Evan Martin) housed at Hakea Prison between 1 January 2023 and 9 March 2023.

 

Any such prisoner is to be referred to as ‘Prisoner [Initial]’.

  1. On the basis it would be contrary to the public interest, the Court makes an order under section 49(1)(b) of the Coroners Act 1996 (WA) that there be no reporting or publication of the details of any evidence regarding the current organisation or unit allocation of cohorts of prisoners with protection status.

Summary : Mr Bropho was a remand prisoner placed in Unit 10, a protection unit, at Hakea Prison when, on 9 March 2023, he was violently killed in his cell by Evan James Martin, another prisoner housed within the unit. Mr Martin was convicted of the murder of Mr Bropho by the Supreme Court of Western Australia, and on 8 March 2024 sentenced to a term of life imprisonment with a minimum non-parole term of 21 years.

Forensic pathologists formed the opinion that Mr Bropho had died from injury to the neck on a background of atherosclerotic heart disease.

The coroner held a mandatory inquest, accepting the cause of death identified by the forensic pathologists, and determining the manner of Mr Bropho’s death was unlawful homicide.

The coroner considered issues including: (a) the information available to the Department in late 2022 and early 2023 regarding the risk Mr Martin posed to prisoners housed in protection units at Hakea charged with sexual offences against children such as Mr Bropho; (b) the maintenance, and any review, of Mr Martin’s status as a protection prisoner during that time; (c) Mr Bropho’s transfer to Unit 10 due to threats made toward him; (d) a physical attack on Mr Bropho by other prisoners on 8 March, and whether that attack was known to any prison staff; and (e) the lock-up procedure on the evening of 8 March 2023, and whether injuries to Mr Bropho should have been identified.

The coroner concluded that there was a missed opportunity in relation to the issue at (b) above. The coroner otherwise concluded that the medical treatment provided to Mr Bropho generally, and in the emergency response on 9 March, was satisfactory.

Catch Words : Death in Custody : Unlawful homicide : Supervision Treatment and Care : Protection prisoner


Last updated: 18 December 2025

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