Coroner's Court of Western Australia

Inquest into the Death of Alf Deon EADES

Inquest into the Death of Alf Deon EADES

Delivered on : 12 June 2024

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations :Yes

Recommendation No. 1

Given the critical importance of responding to cell calls in an appropriate and professional manner, the Department of Justice should consider issuing a Commissioner’s Bulletin (or similar) reminding all custodial staff of the importance of complying with relevant policies (e.g.: Hakea Prison’s Local Order 45 Cell Call Alarms).

Recommendation No. 2

In order to ensure that custodial staff receiving cell calls can be identified, the Department of Justice should consider amending its cell call policy so that when responding to a prisoner’s cell call, custodial staff are required to say: “Officer [Surname], state your name and the nature of your emergency”.

Recommendation No. 3

The Department of Justice should reinforce the protocols for reporting any issues relating to the cell call system at Hakea, and the requirement to conduct regular audits of the cell call system.  The Department of Justice should also ensure that any remedial action required to address any issue with the cell call system is completed as soon as practicable.

Recommendation No. 4

In order to better manage prisoners at Hakea Prison, the Department of Justice should seek internal funding to ensure that closed circuit cameras (CCTV) are installed in all remaining accommodation units not currently fitted with CCTV.  The installation of these additional CCTV should be completed as a matter of urgency.

Recommendation No. 5

The Department of Justice should consider amending its policies to make it clear that if a cell is breached during a period of lockdown as a result of concerns for any of the cell’s occupants, custodial staff are required to speak separately to all occupants of the cell to ensure that all relevant issues are fully investigated.

Recommendation No. 6

The Department of Justice should consider providing training to all custodial staff in the effective management of prisoners with personality disorders, common mental health illnesses, and/or common behavioural issues.

Recommendation No. 7

The Department of Justice should consider amending relevant policies to ensure that when a prisoner does not attend a scheduled medication parade to receive prescribed medication, clinical staff must, where the missed medication is significant, inform the senior officer of the relevant unit that the missed medication is significant and needs to be given to the prisoner as a matter of urgency.  Appropriate steps must then be taken to ensure that the prisoner is provided with the missed medication as soon as is practicable.

Orders/Rules : No

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 Prison between 1 March 2019 and 11 March 2019.  Any such prisoner is to be referred to as “Prisoner [Initial]”.

Summary : Alf Dean Eades (Alf) was 46-years of age when he died at Royal Perth Hospital (RPH) on 11 March 2019 from head injury complicated by bronchopneumonia.

On 26 February 2019, Alf was a remand prisoner at Hakea Prison (Hakea), when he was brutally assaulted in his cell by a number of other prisoners and was seriously injured.  Several prisoners were subsequently convicted of Alf’s murder.

Alf was taken to RPH, where his neurological state was closely monitored.  Alf he failed to show any signs of improvement and his prognosis remained poor.  Following discussions between Alf’s family and his treating team, it was decided to withdraw active treatment, and Alf died shortly after he was extubated.

The Coroner examined the response of two prison officers to cell calls made from Alf’s cell on 26 February 2019, and concluded that many of those response were highly inappropriate and unprofessional, and constituted a serious breach of the Department of Justice’s Code of Conduct.

The coroner also concluded that the supervision and care provided to Alf during his last incarceration at Hakea was demonstrably unacceptable.  The coroner identified a number of missed opportunities where Alf’s safety and welfare could have been more comprehensively assessed.  The coroner also found that the lack of a response to Alf’s cell call at 3.45 pm on 26 February 2019 (in which he said other prisoners were alleging he was a child sex offender) was a major failure.

Catch Words : Death in custody : Assault : Murder : Failure to respond to threats : Unlawful homicide

Last updated: 30-Jun-2024

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