Inquest into the Death of Ricky-Lee COUND
Inquest into the Death of Ricky-Lee COUND
Delivered on : 10 March 2025
Delivered at : Perth
Finding of : Coroner Urquhart
Recommendations : Yes
Recommendation No. 1
In order to enhance the care of prisoners with FASD, the Department introduces mandatory training regarding the management and care of prisoners with FASD to new prison officers undertaking training at the Corrective Services Training Academy and to current prison officers.
Recommendation No. 2
In order to enhance the care of prisoners with FASD and other intellectual disabilities, the Department reviews its operating policies and procedures in order to provide specific guidance to Health Services and custodial staff as to the management and care of these prisoners. Further, this review should address how these prisoners can be supported to manage their intellectual disabilities.
Recommendation No. 3
In order to enhance the care of prisoners, the Department is to ensure it applies the relevant provisions of the Sentencing Act 1996 (WA) in order to use court-ordered psychiatric or psychological reports prepared for the sentencing process of a prisoner who is subsequently sentenced to an immediate term of imprisonment. The Department should continue its efforts to formalise its internal information sharing practices to ensure its Health Services staff are aware of the existence of such reports and can readily access them.
Recommendation No. 4
In order to enhance the care of prisoners and thereby the security of the prison, custodial staff directly responsible for the care of prisoners with diagnosed mental health conditions or intellectual disabilities that may affect their behaviour and/or how they are managed, are informed of these disorders without requiring them to access TOMS in order to obtain that information.
Recommendation No. 5
The Department continues to take necessary and practical steps directed towards investment in body-worn cameras for prison officers at Hakea.
Recommendation No. 6
In order to better manage vulnerable prisoners and thereby enhance security, the Department should take immediate steps to ensure all cells at Hakea are three-point ligature minimised as quickly as possible, with a view to ensuring all cells at Hakea are fully ligature minimised over time. Further, the Department should conduct an urgent review of all three-point and fully ligature minimised cells at Hakea to ensure those cells are fit for purpose and in particular, that the light fittings in those cells can properly be described as “ligature approved”.
Recommendation No. 7
In order to improve the provision of health care (including mental health care) to prisoners, the Department should, as a matter of utmost urgency, prioritise the funding for works to improve the infrastructure used to provide health care at Hakea.
Recommendation No. 8
In order to better manage vulnerable prisoners, the Department introduces an operational policy that requires the placement in a safe cell of a prisoner who has made that request due to the prisoner’s concerns they may self-harm. If the placement does not occur, there must a sound basis for doing so and only after consultation with the prison’s MHAOD services. The reason(s) for not complying with the prisoner’s request must be recorded.
Orders/Rules : N/A
Suppression Order : Yes
There will be no reporting or publication of the name, picture or any other identifying features of Special Operations Group officers called to give evidence in this inquest or Special Operations Group officers who may be referred to in evidence at the inquest.
Summary : On 25 March 2022, Ricky-Lee Cound (Mr Cound) died at Fiona Stanley Hospital, Murdoch, from ligature compression of the neck (hanging). He was 22 years old.
At the time of his death, Mr Cound was a sentenced prisoner at Hakea Prison (Hakea) and was in the care of the CEO of the Department of Justice (theDepartment). As he was a person held in care, his death was subject to a mandatory inquest.
Mr Cound was the first adult prisoner in the state to have died in custody who had been formally diagnosed with Foetal Alcohol Spectrum Disorder (FASD).
On 3 March 2022, Mr Cound was transferred from Acacia Prison (Acacia) to Hakea after he was involved in a riot that had caused significant damage to infrastructure at Acacia. Following this riot, he had been placed on the At Risk Management System (ARMS) due to self-harming. Mr Cound remained on ARMS following his transfer to Hakea.
Mr Cound’s disruptive behaviour continued at Hakea and he was placed in BWing at Unit 1 which is Hakea’s management unit. On 24 March 2022, he tested positive for COVID-19. At about 1.30 pm on 25 March 2022, MrCound was removed from ARMS.
At 4.11 pm on 25 March 2022, Mr Cound used his cell’s intercom system (known as a cell call) to request a placement into a CCTV-monitored cell so that he didn’t self-harm. The prison officer who answered Mr Cound’s cell call arranged for a senior prison officer to speak to Mr Cound. After a short conversation with Mr Cound, the senior prison officer arranged for him to be given a radio and when that was not available, Mr Cound was provided a breakfast pack. He was not placed in a cell with CCTV monitors, nor was he placed on ARMS.
At about 4.43 pm, Mr Cound and two prisoners in other cells in Unit 1’s B Wing broke their cell doors’ viewing windows and propelled broken glass and parts of fans from their cells into the corridor. Although there was broken glass inside Mr Cound’s cell, his cell was not checked or cleaned by prison staff.
At 6.58 pm, Mr Cound was last seen alive when a prison officer saw him through his broken cell door viewing window. Mr Cound was standing inside his cell.
At 7.09 pm, another prisoner in B Wing made a cell call urging prison officers to check Mr Cound who he said was “cutting up” and “blood’s everywhere”. However, at the same time of that call, the two prison officers in Unit 1 had seen water flowing down the corridor in D Wing of Unit 1 and a decision was made to attend that matter first. The prison officers went to DWing and began the task of cleaning up the water in the corridor which was regarded as a potential hazard. As they were doing that, they discovered a prisoner in D Wing had a plastic bag over his head and was threatening self-harm. He was also armed with a piece of metal.
During the time these prison officers were in D Wing, Hakea’s master control room were receiving cell calls from prisoners in B Wing who were very concerned for Mr Cound’s welfare as he had not responded to them for some time. The content of those calls was conveyed to one of the prison officers in Unit 1. He advised he would respond after he had dealt with the incidents in D Wing.
At 7.26 pm, the two prison officers in Unit 1 went to B Wing and a check was made of Mr Cound through the broken viewing window of his cell door. He was seen hanging unresponsive by a bed sheet that had been attached to the cell’s ceiling light casing. This casing had been damaged, which meant the bed sheet could be threaded through two gaps that had been made. This enabled the casing to be used as an anchor point.
Mr Cound was quickly taken down and extensive resuscitation efforts were performed by prison officers, prison nursing staff and attending ambulance officers. However, Mr Cound could not be revived and he was later confirmed to have died at Fiona Stanley Hospital.
The Coroner found that there was a missed opportunity by Department staff in not placing Mr Cound on the Support and Monitoring System (SAMS) after he had been taken off ARMS on 25 March 2022.
The Coroner also found that Mr Cound should have been placed on ARMS and into a safe cell following his 4.11 pm cell call as he had stated a potential risk of self-harming. The Coroner was satisfied that the failure to place Mr Cound on ARMS and into a safe cell contributed to his death several hours later. Had he been in a safe cell, the risk of Mr Cound being able to end his life would have been significantly lower than the level of risk that existed within his cell in B Wing.
Although the Coroner accepted the reasoning behind the prison officers attending D Wing before their check on Mr Cound, there were several missed opportunities identified that had they been taken, were likely to have reduced the time it took for the check on Mr Cound to take place.
The Coroner was not satisfied that the care and management of Mr Cound’s FASD was appropriate. The Coroner found that the Department was responsible for that as the Department’s Health Services were required to perform in an under-staffed and under-resourced environment within the prison estate.
Although the Coroner was satisfied some improvements and changes had been made by the Department since Mr Cound’s death, a lot more still needed to be done to lower the risk of suicide amongst vulnerable prisoners, particularly those who are First Nations.
The Coroner made eight recommendations, with an emphasis on the treatment and care pf prisoners with FASD and other intellectual disabilities, and on reducing the risk of suicide amongst prisoners.
Catch Words : Mandatory Inquest : Death in Custody : Sentenced Prisoner : FASD : Mental Health : Supervision, Treatment and Care : Recommendations : Suicide
Last updated: 25 March 2025