Inquest into the Death of Sam Phillip Chisholm LYNCH
Inquest into the Death of Sam Phillip Chisholm LYNCH
Delivered on : 12 June 2025
Delivered at : Perth
Finding of : Coroner Jenkin
Recommendations : Yes
Recommendation No. 1
To enhance the safety of prisoners and staff at Hakea Prison (Hakea), and to prevent any future loss of life, the Department of Justice (the Department) should install a fire suppression system at Hakea so that all cells and common areas are protected in the event of fire. The Department should consider whether this initiative can be funded by way of an internal funding allocation, or whether it is necessary to seek additional funding from the Treasury.
Recommendation No. 2
To ensure the safety of prisoners and staff at Hakea Prison (Hakea) the Department of Justice (the Department) should expedite a ban on smoking at Hakea, and take all reasonable steps to ensure that prisoners do not have access to tobacco products (including cigarettes), matches and/or lighters. To ensure the good order and safety of prisoners at Hakea whilst the smoking ban is being implemented, the Department should ensure that all prisoners who were smokers are given access to nicotine substitutes (e.g.: patches, lozenges), and support services including counselling, and diversionary activities.
Recommendation No. 3
To ensure the safety of prisoners and staff at Hakea Prison, whilst the initiatives referred to in Recommendations 1 and 2 are being implemented, the Department of Justice should develop and institute an interim management policy to restrict access to lighters and matches by prisoners with a heightened risk profile, including but not limited to prisoners convicted of arson and/or prisoners who have lit fires in prison.
Recommendation No. 4
To ensure the safety of prisoners and staff at Hakea Prison (Hakea), the Department of Justice should enhance the preparedness of staff at Hakea to respond to fires by all possible means, including by:
- Reviewing Hakea’s Emergency Management Plan and Fire Safety Plan to ensure they are fit for purpose and effectively implemented;
- Conducting refresher training for custodial staff on first response to fire including safe work procedures the use of R kits; fire extinguishers; fire blankets; and fire hoses, using realistic scenarios and environments;
- Enhancing the skills of officers qualified to use Breathing Apparatus (BA) by:
- Conducting quarterly BA training exercises using realistic scenarios;
- Requiring all BA qualified officers to conduct monthly don and doff practices (under air) with BA equipment and PPE;
- Providing additional training for officers willing to assume the position of Entry Control Officer;
- Enhancing incentives (whether financial or otherwise) to encourage custodial officers to maintain the currency of their BA qualification; and
- Developing a system to ensure that staff in the Master Control Room at Hakea are aware of all BA qualified officers on shift and their respective locations.
Recommendation No. 5
To ensure the safety of prisoners and staff at Hakea Prison (Hakea), the Department of Justice should expedite the installation of Closed-Circuit TV cameras in all accommodation units and common areas at Hakea.
Recommendation No. 6
To ensure the safety of prisoners and staff at Hakea Prison (Hakea), the Department of Justice should expedite the rollout of Body Worn Cameras for all custodial staff at Hakea.
Recommendation No. 7
The Department of Justice should introduce training packages aimed at officers preparing to undertake the positions of Senior Officer (i.e. Unit Manager), and Principal Officer, respectively. The training packages for these positions should include advanced training in de-escalation techniques for managing disruptive and aggressive prisoners, as well as leadership, tactical commander, and other key skills deemed necessary for officers undertaking in these positions.
Recommendation No. 8
The Department of Justice should redouble its efforts in recruiting and importantly, retaining, suitably skilled custodial officers.
Recommendation No. 9
The Department of Justice (the Department) should take all reasonable steps to ensure that the provisions of “EMF-DIR-022 Operational debriefing” are complied with. In particular, in relation to critical incidents involving deaths in custody, the Department should ensure that wherever possible, personnel involved in the critical incident participate in immediate and formal debriefs, so that valuable insights from those officers can be captured and incorporated into any “lessons learned” process. The Department should also ensure that lessons learned reports are disseminated to relevant staff, including those involved in the management and conduct of emergency response skills.
Recommendation No. 10
The Department of Justice (the Department) should consider providing automatic standdown leave for all staff directly involved in a critical incident, including, but not limited to, incidents involving a death in custody. The Department should also take all reasonable steps to ensure that all relevant staff are provided with the “stress checks and support mechanisms” referred to in “EMF-DIR-022 Operational debriefing”.
Recommendation No. 11
The Department of Justice should continue the current regime of quarterly checks by external contractors of fire extinguishers and fire hose reels at Hakea Prison (Hakea), and the ventilation ducts at Hakea should be regularly cleaned to remove dust and/or other materials which may represent a fire hazard.
Recommendation No. 12
The Department of Justice should consider amending relevant policies to make it clear that after a prisoner has been declared life extinct by an authorised person, any restraints on the prisoner at that time, should be removed as soon as reasonably practicable.
Orders/Rules : No
Suppression Order : Yes
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 Hakea Prison on or about 5 March 2024. Any such prisoner is to be referred to as “Prisoner [Surname Initial]. Order made by: SH Linton, Acting State Coroner (13.12.24)
Summary : Sam Phillip Chisholm Lynch (Sam) was 27-years of age when she died at Fiona Stanley Hospital on 5 March 2024 from the from the effects of fire, after he set the mattress in his prison cell alight.
At the time of his death, Sam was a remand prisoner at Hakea Prison (Hakea) and therefore in the custody of the Chief Executive Officer of the Department of Justice (the Department).
About 6.00 pm, prison officers in Unit 7 were securing prisoners in their cells as part of Hakea’s standard nighttime “lockdown”, and Sam was secured in his cell without incident. Sam was told he would not be receiving his “canteen spends” and this appears to have caused him to become very agitated and distressed.
At about 6.05 pm, banging noises were heard from Sam’s cell (G12) and it became clear that he was damaging the fixtures and fittings in his cell. Efforts to engage with Sam were unsuccessful, and he placed his mattress against the cell door blocking the view of officers into the cell through the cell door’s observation hatch.
A prison officer went out into a courtyard and looked through a window in the back wall of G12. The officer heard Sam say: “You know what happens next, I light it up”, before he used a cigarette lighter to set fire to middle of the cover of his mattress.
The fire quickly took hold, and attempts by prison officers to deal with the fire were thwarted when the door of the closest fire cupboard (containing a fire hose) was found to be jammed shut, and the nozzle on the fire hose in the next closest fire cupboard was missing a level, meaning the hose could not be operated.
As smoke poured under the door of G12 and into Unit 7 were Sam’s cell was located, a senior prison officer ordered all prison staff to evacuate the unit which they did. Sometime later, officers wearing breathing apparatus arrived and Sam was extracted from his cell. Other prisoners on the unit were then removed from their cells, as prison officers and nursing staff made frantic efforts to resuscitate Sam.
Sam was taken to FSH by ambulance, but despite further resuscitation efforts he could not be revived. Sam was declared deceased at 8.08 pm on 5 March 2024.
The coroner was satisfied that the management of Sam’s physical and mental health at Hakea was appropriate, and that the standard of treatment and care he received during his last brief period of incarceration was acceptable.
However, the coroner concluded that the standard of supervision Sam received at Hakea was grossly and manifestly inadequate. The coroner found that inability of Hakea’s custodial staff to effectively respond to the fire in Sam’s cell was adversely affected by a range of factors.
These factors include: the lack of an automatic cell fire suppression system, the ready access by prisoners to cigarette lighters, the lack of serviceable fire-fighting equipment on Unit 7, the poor maintenance of fire cupboard doors and fire hoses, and the chronic and ongoing staff shortages resulting in adequate supervision of prisoners.
In this case, after Sam was seen to light a fire in his cell it took 16 minutes for officers wearing breathing apparats to extract him from his cell. By that stage Sam was unresponsive, and despite resuscitation efforts at Hakea and FSH, he could not be revived.
The coroner acknowledged that since Sam’s death, staff at Hakea have made concerted efforts to improve the preparedness of staff to deal with fires. However, the coroner said the fact remains that staff and prisoners at Hakea remain at grave risk from the effects of fire.
That is because prisoners (even those with a demonstrated history of committing arson and/or of lighting fires in their cells) have ready access to cigarette lighters, and the fact that there is no automatic fire suppression system in cells at Hakea.
The coroner accepted that addressing the access prisoners at Hakea currently have to cigarette lighters raises complex issues. The coroner also noted that the prison population at Hakea is currently very large, and that ongoing staff shortages mean prisoners are subjected to “adaptive regimes” meaning they spend longer periods in their cells. The environment at Hakea is therefore tense and difficult to manage.
The coroner also accepted that retrofitting an automatic fire suppression system in cells at Hakea is logistically challenging and prohibitively expensive. Nevertheless, the coroner said that given the grave risks from fire that prisoners and staff at Hakea difficult decisions must be taken.
The coroner made 12 recommendations aimed at improving the safety and welfare of prisoners and staff at Hakea.
Catch Words : Death in Custody : Cell fire : Lack of fire preparedness : Lack of fire suppression system : Smoking ban : Accident
Last updated: 3 July 2025