Coroner's Court of Western Australia

Inquest into the Death of Barry Matt STUART

Inquest into the Death of Barry Matt STUART

Delivered on :7 March 2017

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes

I recommend that the Department of Corrective Services, when planning what future changes are to be made to the mental health services it provides to prisoners, should invest significantly more resources in ensuring that prisoners are given regular access to psychiatrists and that overall an emphasis be placed on providing a more holistic approach to mental health care.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was a sentenced prisoner at Hakea Prison at the time of his death. He was 49 years old.  At the time of his death he was a person held in care, therefore, pursuant to section 22(1)(a) of the Coroners Act 1996 it is mandatory to hold an inquest into his death.

The issues which were explored at the inquest hearing primarily focused on the medical care provided to the deceased in prison prior to his death, as well as his resuscitation by paramedics in consultation with a doctor at the Fremantle Hospital.

The deceased had a known history of depression, drug induced psychosis, hepatitis C and previous attempts of self-harm. He also had a documented history of variable compliance with medications for the treatment of psychosis and depression.

The deceased had been prescribed medication to treat psychotic symptoms he had experienced in the past. It appears a secondary benefit the deceased received was to assist him to sleep.  A concern was raised regarding whether the prescribing of this medication should continue.  It was an ongoing theme in the deceased’s records for his last period of imprisonment.  Records also indicated that the deceased should be reviewed by a psychiatrist.  Unfortunately, there was a severe shortage of psychiatric appointments at Hakea Prison at that time and as a result the deceased went several months without seeing a psychiatrist.

The Coroner concluded that the psychiatric care provided to the deceased in this case was less than the standard one would expect to be provided for a prisoner, and the lack of psychiatric review of the deceased contributed to the deceased’s decision to take his own life. In this context the Coroner made the recommendation in respect to the future planning of the mental health services within the WA Prison System.

The Coroner concluded the deceased took his own life on 16 November 2013 at Hakea Prison as a result of ligature compression of the neck (hanging) and found death was by way of suicide.

Catch Words : Death in Custody : Medical Management of Prisoners : Psychiatric Services in a Prison Environment : Future Planning for Mental Health Services : Suicide.

Last updated: 14-Mar-2017

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