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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

Home →Inquest Findings→Inquest Findings 2019→Capper, Bret Lindsay

Inquest into the Death of Bret Lindsay CAPPER

Inquest into the Death of Bret Lindsay CAPPER

Delivered on : 13 November 2019

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

 Recommendation No. 1

The Department should review the deployment procedure for the Special Operations Group (SOG) and in doing so, should consider the views of experienced custodial and operational officers, that the current system is inefficient. The Department should give consideration to reverting to the previous deployment system where officers in charge of prisons could contact SOG directly when seeking assistance.

Recommendation No. 2

Now that funding for nine additional Prison Counselling Service (PCS) staff has been approved, the Department should take urgent steps to recruit these staff and more broadly, should consider the appropriate level of PCS and mental health staff for prisons across the State.

Recommendation No. 3

In order to better manage prisoners and thereby enhance security at Hakea Prison, the Department should, without delay, take all necessary steps to remove any remaining impediments so as 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 No. 4

The Department should consider expanding the delivery of information sessions about the SOG (currently being presented to prison health staff) to custodial officers.

Recommendation No. 5

In order to better manage prisoners and thereby enhance security at Hakea Prison, the Department should consider providing critical incident management training to its senior custodial officers (i.e.: senior officers and above).

Recommendation No. 6

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

Orders/Rules : N/A

Suppression Order : N/A

Summary : Until shortly before his death, the deceased was being held in custody on remand at Hakea Prison. He died on 14 January 2016 at Fiona Stanley Hospital as a result of bronchopneumonia and brain swelling following ligature compression of the neck (hanging). He was 43 years of age.

On 12 January 2016, the deceased had barricaded himself into a communal area in the prison wing he was being housed in. Despite the efforts of prison officers, the deceased placed an improvised ligature around his neck and hanged himself. He had told other prisoners and custodial staff that he could not face the long prison sentence he anticipated he would receive.

Officers for the Special Operations Group (SOG) were deployed to Hakea Prison and used specialist equipment to gain access to room where the deceased was located. The deceased was given first aid and transported to Fiona Stanley Hospital.

The deceased had sought counselling for his mental state on 30 October 2015, but because there were not enough counsellors at Hakea Prison at the time, he was seen on only one occasion. The deceased had previously been diagnosed with antisocial personality disorder and the evidence at the inquest was that he would have benefitted from long-term counselling, had this been available. The Coroner found that the deceased was not placed on the Prison’s Support and Monitoring system after being removed from At Risk Management System on 20 October 2015. Had this occurred, the deceased would have been monitored more regularly by the Prison At Risk Management Group and may have been more likely to have received ongoing counselling.

Since the deceased’s death, physical changes have been made at Hakea Prison to prevent other prisoners from barricading themselves into communal areas. The Coroner made six recommendations aimed at addressing the issues identified during the course of the inquest, including the provision of adequate counselling services and the deployment process for the SOG.

Catch Words : Incident Management Training : Deployment of SOG : Negotiator Training : Ligature Minimisation : Adequate Mental Health Support in a Prison Setting : Suicide.


Last updated: 23-Mar-2020

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