Inquest into the Death of Sean Theo WINMAR (Mr STW)
Inquest into the Death of Sean Theo WINMAR
Delivered on : 23 January 2026
Delivered at : Perth
Finding of : Acting State Coroner Linton
Recommendations :
- I recommend the Department of Justice review the staffing requirements and resourcing of the FPIT, to consider whether there are ways to improve the staffing levels in order to reduce the length of the waitlist. Alternatively, the Department of Justice should explore alternative ways to provide psychological support to supervised offenders subject to both interim supervision order and final supervision orders.
- I recommend WA Police and Department of Justice staff involved in supervising persons on HRSO Act orders should receive regular training in culturally safe and trauma informed interactions, above and beyond the standard cultural awareness training provided to staff as part of their standard agency induction and training.
- I recommend the Department of Justice amend the policies for HRSO Act orders to ensure that Community Corrections Officers are required to ensure a person subject to the order (interim or final) is offered appropriate psychological and substance use support related to their identified risk factors from the outset of the order. If the FPIT does not have the capacity to provide that support, then appropriate alternatives should be sourced to provide that support within the framework of the Department’s overall supervision requirements.
- I recommend the Department of Justice ensure that there is an independent Aboriginal and/or Torres Strait Islander representative at HRSO Review Committee meetings.
Orders/Rules : N/A
Suppression Order : That there be no reporting or publication of Chapter 10 and Chapter 16 of the Adult Community Corrections Handbook on the basis that it would be contrary to public interest.
Summary : Mr STW was a Whadjuk and Ballardong Nyungar Aboriginal man who grew up in a close, loving family. He enjoyed traveling to places across Nyungar country and spending time with his family. He was born in 1976 and was 46 years old at the time of his death.
Unfortunately, as an adult Mr STW began using drugs and alcohol, which resulted in a pattern of offending that led to a considerable portion of his adult life being spent in custody. His substance use and history of reoffending also had a detrimental impact on his mental health at times.
Mr STW’s offending behaviours escalated over time and he committed a number of offences involving violence, such as grievous bodily harm and armed robbery. This offending resulted in Mr STW serving a number of lengthy periods in custody. He also spent periods of time in hospital as an involuntary patient due to drug-induced psychosis and risk of suicide.
Mr STW’s family loved him very much and tried to support him in efforts to rehabilitate himself, but he was a strong-willed person and he made his own decisions. Although he had periods of sobriety, he would eventually fall back into substance use, which then led him back into custody.
Mr STW had a significant long term relationship and had three sons with this partner. The relationship was said to be volatile and impacted by substance misuse, mental health issues and violence. Mr STW was not always able to be physically present in his children’s life, but he continued to love them and tried his best to remain connected with them as they grew up and began to have children of their own. He also had a close and enduring relationship with his eldest sister, who had helped to raise Mr STW when he was young, alongside her own children.
Due to his substance use and reoffending history, prior to the end of his last period of imprisonment an application was commenced for Mr STW to be subject to the HRSO Act. An interim order was made and Mr STW was released on an interim supervision order under the Act. He was required to abide by extensive conditions under the order, including a curfew, regular urinalysis and electronic monitoring. He signed and accepted those conditions prior to being released. Mr STW moved into supported accommodation at The Beacon, which is run by The Salvation Army.
He found the nature of the restrictive order difficult to comprehend and he struggled to comply with the many conditions. Mr STW appeared to have a positive mindset and was trying very hard to avoid drugs and alcohol and anyone who might tempt him to fall back into substance use. In the first few months after his release, Mr STW was doing driving lessons, had found a job he enjoyed, was attending church and spending quality time with family.
Mr STW received some support from The Beacon staff and some service providers connected with The Beacon while being supervised and monitored by Department of Justice staff and WA Police Force officers. Unfortunately, during this time, he was not receiving any supportive counselling or formal substance abuse support as part of his supervision, despite voicing thoughts of suicide at least once. He had been referred to the Department’s Forensic Psychology Intervention Team (FPIT) but had been waitlisted due to significant demands on FPIT resourcing.
Mr STW had taken his own steps with his doctor to be admitted to a drug and alcohol detoxification centre, and it appears his referral to FPIT was put in abeyance to allow him to attend Bridge House.
The Acting State Coroner found there were missed opportunities to provide more support to Mr STW when it became apparent he was struggling to comply with the terms of his interim supervision order.
On the evening of 8 August 2022, Mr STW hanged himself in his room at The Beacon hostel with an intention to end his life. He was discovered by hostel staff shortly after his girlfriend requested them to check on his welfare. They called emergency services for help and Mr STW was taken by ambulance to hospital and provided with intensive medical care, but he had suffered an irreversible brain injury, which led to his death on 11 August 2022.
The Acting State Coroner found Mr STW died due to complications of ligature compression of the neck and the manner of death was by way of suicide.
Catch Words : Aboriginal death: Mandatory Inquest: Death in Care: HRSO Act: Hanging: Suicide:
Last updated: 13 February 2026