Inquest into the death of Kingsley Dean Garlett
Delivered on : 15 November 2024
Delivered at : Perth
Finding of : Coroner Jenkin
Recommendations :
Recommendation No. 1: In order to better manage prisoners and thereby enhance security at Casuarina Prison (Casuarina), the Department should, as a matter of the utmost urgency, take immediate steps to ensure all cells at Casuarina are three-point ligature minimised as quickly as possible, with a view to ensuring all cells at Casuarina are fully ligature minimised over time. Further, the Department of Justice should finalise its review of all bunk beds in cells at Casuarina, and as soon as practicable should ensure that all bunk beds at Casuarina are fit for purpose and in particular, can properly be described as “ligature approved”.
Recommendation No. 2: In order to provide strategic guidance to its efforts to reduce the flow of illicit substances into prisons, the Department of Justice should implement a replacement strategy for the now expired Western Australian Prisons Drug Strategy 2018 - 2021.
Recommendation No. 3: In order to improve the support provided to prisoners, the Department of Justice should take urgent steps to recruit additional prison counsellors and Aboriginal Support Workers for Casuarina Prison. More broadly, the Department of Justice should review staffing levels of prison counselling staff and mental health staff at prisons across the State to determine if these levels are appropriate.
Recommendation No. 4: In order to better manage prisoners at Casuarina Prison who have polysubstance use issues, the Department of Justice should consider expanding its methadone and buprenorphine programs so that the wait time for prisoners to enter these programs is reduced.
Orders/Rules : No
Suppression Order :
On the basis that it would be contrary to the public interest, pursuant to section 49(1)(b) of the Coroners Act 1996 that there be no reporting or publication of the name of any prisoner (other than the deceased) housed at Casuarina Prison on or about 31 July 2022. Any such prisoner is to be referred to as “Prisoner [Surname Initial]”; and no reporting or publication of any document or evidence that would reveal any information about the methods of detecting illicit drugs with respect to persons under the care and control of the Director-General of the Department of Justice.
Summary : Kingsley Dean Garlett (Mr Garlett) died at Casuarina Prison (Casuarina) on 31 July 2022, from ligature compression of the neck. He was 32 years of age.
Mr Garlett had an extensive criminal history. As an adult, he accumulated 46 convictions for offences including: stealing, assault, aggravated burglary, armed robbery, and unlawful wounding. From about 2009, Mr Garlett was imprisoned on 11 occasions and he therefore spent the majority of his adult life in custody.
On 14 February 2020 in the District Court at Perth, Mr Garlett was sentenced to seven years’ imprisonment in relation to the offences of: aggravated armed robbery, assault occasioning bodily harm, steal motor vehicle, reckless driving, aggravated home burglary, aggravated assault, and threats to injure, endanger or harm a person.
Mr Garlett’s medical history included: gastro-oesophageal reflux disease, cellulitis, tachycardia (increased heart rate), depression, thoracic/lumbar pain, and acute renal impairment following an accident in 2019.
Mr Garlett had received treatment for various fractures, and he also had a history of polysubstance use including methylamphetamine (from 13 years), heroin (from 15 years), and cannabis dependence since 2011. It also appears Mr Garlett had emotionally unstable personality disorder.
On 30 and 31 July 2022, Mr Garlett had a number of telephone conversations with his partner. During these calls, it was clear that Mr Garlett clearly believed his partner was being unfaithful to him, despite her repeated denials. During some of these calls, Mr Garlett expressed suicidal ideation and it appears his mental state was deteriorating.
Shortly after 11.45 am on 31 July 2022, Mr Garlett was locked in his cell for lunch. At the time, he was the sole occulpant in a double occupancy cell, and none of the custodial staff invloved in the lockup noticed anything unusual about Mr Garlett’s behaviour.
At about 1.35 pm custodial staff conducting the unlock procedure after lunch found Mr Garlett hanging in his cell, with a ligature aound his neck that was tied to the bunk bed in his cell. The ligature was removed from Mr Garlett’s neck and custodial staff started CPR. Ambulance officers arrived and took over resuscitation efforts, but Mr Garlett could not be revived, and he was declared deceased.
Toxicological analysis detected the medications amitriptyline, quetiapine and diazepam in Mr Garlett’s system, none of which he had been prescribed. The analysis also detected cannabis and methylamphetamine.
After carefully considering the available evidence, the coroner was satisfied that the treatment and care that Mr Garlett received whilst he was incarcerated was of an acceptable standard.
However, on ther bsis that Mr Garlett was able to access illicit drugs, and medications he was not prescribed whilst he was in custody, the coroner concluded that the standard of supervision Mr Garlett received at Casuarina was inadequate.
The coroner made four recommendations aimed at improving the safety and welfare of prisoners at Casuarina.
Catch Words : Death in custody : Illicit access to prescription drugs: Methylamphetamine use : Cannabis use : Ligature minimisation: Suicide
Last updated: 13 December 2024