Inquest into the Death of Corey Desmond DEVREE
Delivered on: 28 April 2026
Delivered at: Perth
Finding of: Coroner Jenkin
Recommendations: Yes
Recommendation No. 1
In order to better manage prisoners and thereby enhance security at Bunbury Regional Prison, the Department of Justice (the Department) should, without delay, take all necessary steps to reduce the number of outstanding treatment assessments. The Department should consider measures including, but not limited to:
- Streamlining the assessment process;
- Placing greater reliance on external reports from psychiatrists, psychologists (where available) when assessing a prisoner’s treatment needs; and
- Engaging additional psychologists (whether on a full-time, part-time, or contract basis) to conduct treatment assessments.
Recommendation No. 2
The Department should undertake an urgent review of Commissioner’s Operating Policy and Procedure (COPP) 8.1 - Prison Based Constructive Activities to ascertain if a definition of direct/indirect supervision level is required and if so, clarify issues relating to safety and security parameters.
Recommendation No. 3
The Department of Justice i.e.: (the Department) should conduct an urgent review to determine the appropriate levels of supervision for prisoners working in the Industries area at Bunbury Regional Prison (i.e.: Paint Shop, Metal Shop, Cabinet Shop etc). The review should also consider:
- Determining the minimum supervision levels appropriate for the Industries area workshops, and the minimum acceptable ratio of Vocational Support Officers to prisoners;
- The minimum supervision levels appropriate for the Industries area workshops, and the minimum acceptable ratio of Vocational Support Officers to prisoners;
- The feasibility of installing Close Circuit TV cameras in Industries area workshops so as to allow remote monitoring by prison officers on duty in the Multi-Function office; and
- A policy of closing Industry workshops when the identified basic level of supervision cannot be provided.
Recommendation No. 4
The Department of Justice should institute a mechanism for regularly checking all Automated External Defibrillators (AED) at Bunbury Regional Prison to ensure that each AED has a spare set of defibrillator pads.
Orders/Rules: No
Suppression Order:
On the basis that it would be contrary to the public interest there be no reporting or publication of the name of any prisoner (other than the deceased) housed at Bunbury Regional Prison on or about 14 October 2024. Any such prisoner is to be referred to as “Prisoner [Surname Initial]”. Order made by: MAG Jenkin, Acting Deputy State Coroner (31.03.26)
Summary:
Corey Desmond Devree (Corey) was a sentenced prisoner, and was 41-years of age when he died on 14 October 2024 at Bunbury Regional Prison after stabbing himself in the chest and hanging himself.
The Acting Deputy State Coroner found that although the standard of care and treatment Corey received whilst incarcerated was adequate, regrettable that neither Corey’s disclosure of feeling anxious and hearing voices (i.e.: on 21 August 2024), nor his request for an appointment with a nurse “ASAP” (14 October 2024) were met with a more assertive response. The Acting Deputy State Coroner also found that with two exceptions, Corey’s custodial management and supervision during his incarceration was adequate. The two exceptions were:
- The Department’s failure to conduct a timely assessment of Corey’s treatment needs, which the Acting Deputy State Coroner found was reprehensible; and
- The standard of supervision Corey received while he was working in the Paint Shop on 14 October 2024 which the Acting Deputy State Coroner found was demonstrably poor.
The Acting Deputy State Coroner made four recommendations.
Catch Words: Death in Custody : Hanging : Self-inflicted stab wound : Inadequate supervision : Lengthy delays in assessing treatment needs : Suicide
Last updated: 8 May 2026