Inquest into the Death of Wayne Thomas LARDER
Inquest into the Death of Wayne Thomas LARDER
Delivered on : 28 November 2020
Delivered at : Perth
Finding of : Coroner Jenkin
Recommendations : Yes
Recommendation No. 1
In order to enhance the effectiveness and integrity of the deliberations of the Prisoner At Risk Assessment Group (PRAG), the Department should:
- introduce face-to-face training for PRAG Chairs incorporating scenario-based training, roleplays and other appropriate delivery methods to educate, assess and support staff fulfilling the important role of PRAG Chair;
- establish a Suicide Prevention Governance Unit (the Unit) in order to (amongst other things) provide a system of formal quality assurance, oversight, and auditing of PRAG decisions. The Unit would promote consistency and best practice in the application of the At Risk Management System (ARMS) and provide advice and training to PRAG members;
- reinforce the importance of the PRAG carefully considering static and dynamic risk factors when assessing a prisoner’s risk of self-harm and/or suicide and in particular, that the PRAG should carefully consider a prisoner’s recent presentation and conduct including any suicidal and/or self-harm ideation and behaviour; and
- require the PRAG to carefully document any decision to reduce a prisoner from High ARMS to Low ARMS and to set out the rationale for that decision, including all relevant factors that prompted that decision - including the important issue of exactly what has changed in the prisoner’s presentation.
Recommendation No. 2
In order to enhance the effectiveness and integrity of the deliberations of the Prisoner At Risk Assessment Group (PRAG), the Department should:
- explore the feasibility of providing all staff required to conduct ARMS assessments with access to the Statement of Material Facts in relation to the offences for which the prisoner has been taken into custody;
- should, as a matter of urgency, improve the way that information obtained by the Department’s senior mental health staff from the Psychiatric Services Online Information Service (PSOLIS) is shared amongst staff who are required to conduct ARMS assessments; and
- give urgent consideration to providing prison mental health nurses with access to the Standardised Risk Management Tool currently being used by Psychological Health Services.
Recommendation No. 3
In order to better manage vulnerable prisoners and thereby enhance security at Hakea Prison (Hakea), the Department should, as a matter of the utmost urgency undertake immediate remedial work at Hakea to ensure that all cells used to house newly admitted prisoners are fully ligature minimised. The Department should also 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 fittings in those cells (e.g.: taps, basins etc) can properly be described as “ligature approved”.
Recommendation No. 4
As has previously been recommended by this Court, and in order to better manage vulnerable prisoners and thereby enhance security at Hakea, the Department should, as a matter of the utmost urgency increase the number of safe cells at Hakea from six to 12.
Recommendation No. 5
The Department should explore the feasibility of introducing regular refresher training for the Gatekeeper program for all prison officers and should include training in the effective management of prisoners with personality disorders and common mental health conditions.
Recommendation No. 6
The Department should conduct a review to determine whether the resources and facilities currently available to staff at Hakea to manage prisoners with complex mental health issues and/or behavioural issues are adequate. The review should consider the feasibility of establishing a unit at Hakea, staffed by mental health practitioners and custodial staff, to enable prisoners with complex mental health issues and/or behavioural issues to be appropriately managed.
Orders/Rules : N/A
Suppression Order : Yes
On the basis that it would be contrary to the public interest, I make an Order under 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 Hakea. Any such prisoner is to be referred to as “Prisoner [Initial]”.
Summary : Mr Wayne Thomas Larder (Mr Larder) died from ligature compression of the neck at Hakea Prison (Hakea) on 22 February 2021. He was 42-years of age.
At the time of his death, Mr Larder was a remand prisoner, and was facing charges of unlawful possession of firearms, attempting to sell firearms, possession of a prohibited drug and breaches of a violence restraining order.
Mr Larder’s had been diagnosed with depression, and in 2016 he was seriously injured when a hale bale fell onto him. He also had a history of polysubstance use, including methylamphetamine.
Whilst he was in custody, Mr Larder was managed on the At Risk Management System (ARMS) and placed in a safe cell on several occasions. During a court appearance by video-link on 19 February 2021, Mr Larder was remanded in custody until 22 February 2021. After the court appearance, Mr Larder was placed in a holding cell and repeatedly ran at the walls before falling to the floor. He later told a mental health nurse, that if he was not released on bail “he would kill himself”.
On 20 February 2021, Mr Larder was placed in a safe cell after consuming medication he had found in his cell. He later claimed he had taken the medication because he thought it “might give him a buzz”. Mr Larder was removed from the safe cell on 21 February 2021, and despite his earlier threats, he was placed in a three-point ligature cell.
Mr Larder made a further court appearance by video-link on 22 February 2021. During the appearance his lawyer told the court that there were significant concerns for Mr Larder’s safety and that everyone “was scared he will commit suicide and he should be on 24-hour watch”. These comments were not conveyed to custodial staff at Hakea Prison, nor were comments Mr Larder reportedly made to another prisoner, namely that if no-one went surety for him in court that day he would kill himself.
Mr Larder was remanded in custody until 28 April 2021, to enable pre-sentence and psychiatric reports to be prepared. As a result of Mr Larder’s demeanour his court appearance, a video-link officer contacted custodial officers on Mr Larder’s unit to let them know Mr Larder was returning and “to keep an eye on him”.
Mr Larder returned to his unit sometime before 11.20 am. At that time, custodial officers were carrying out a muster check before serving the lunchtime meal and nobody had time to speak to Mr Larder. At about 11.30 am, Mr Larder was found hanging with an electrical cord around his neck that was tied to the metal surround of a tap on the basin in his cell.
Custodial staff removed the ligature from around Mr Larder’s neck and started CPR. Ambulance officers arrived and took over resuscitation efforts, but Mr Larder could not be revived.
The coroner found that the management of Mr Larder’s physical health was commensurate with community standards. However, the coroner found that the management of Mr Larder’s mental health was demonstrably suboptimal, and further that his risk of suicide and/or self-harm was not properly appreciated.
The coroner made six recommendations aimed at improving the management of prisoners with complex needs.
Catch Words : Death in Custody : Hanging : Management of suicide risk : Suicide
Last updated: 19-Dec-2022
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