Coroner's Court of Western Australia

Inquest into the Death of Annabel NICOL

Inquest into the Death of Annabel NICOL

Delivered on : 11 July 2019

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes

Recommendation 1
I recommend that the Government commit funding to the establishment of a subacute mental health unit in Bandyup Women’s Prison, properly staffed with a multidisciplinary mental health team, as a matter of priority.

Recommendation 2
I recommend that the Government commit funding to establish a “female only” secure forensic mental health unit as a matter of priority.

Recommendation 3
I recommend that the Honourable Attorney General give consideration to amending the Sentencing Act 1995 (WA) to permit the release of court ordered medical reports to the medical and nursing staff who are treating remand and sentenced prisoners in Western Australia to ensure that this valuable source of information is able to be accessed to improve the level of care and treatment that can be provided to prisoners.

Orders/Rules : N/A

Suppression Order : N/A

Summary : At the time of her death the deceased was a prisoner. She was found hanging in a shower cubicle at Bandyup Women’s Prison, where she was being held on remand.

The deceased started using alcohol at the young age of 15 years, which developed into chronic alcoholism during her marriage. She had suffered with depression and alcohol addiction for many years. She had hospital admissions on at least three occasions after being found collapsed in the street due to acute alcohol intoxication. She had convictions in 2012 and 2013 for driving under the influence of alcohol. On 13 March 2015 the deceased was admitted into Bandyup Women’s Prison as a remand prisoner after being charged with more offences that were alcohol related. This was the deceased’s first lengthy period of incarceration and she found the transition difficult.

On 5 April 2015 the deceased was taken by ambulance to the Swan Hospital Emergency Department and provided hospital staff with a four day history of ingesting multiple cleaning products as well as a metal paperclip two weeks previously. A recommendation was made by the hospital that the deceased have a psychiatric assessment at the prison.

On 8 April 2015 the deceased underwent a medical officer review for her new admission and was referred for psychiatric assessment. On 10 April 2015 the deceased was seen by a mental health nurse and assessed. She did not appear to have any psychiatric history and the conclusion was that she did not need to be seen by mental health staff. After exhibiting distress and behavioural issues, on 28 April 2015 the deceased had her first psychiatric review. The deceased had regular contact within the health services of the prison thereafter, she spent significant period of time in the Crisis Care Unit but was eventually returned to the mainstream population at her request as she wanted more freedom to socialise and to smoke. She initially appeared to be settling well in the mainstream unit.

On the afternoon of 15 June 2016 the deceased approach another prisoner asking for some cleaning product. The deceased appeared to look lost and out of sorts. She was given some cleaning products and shortly after entered the prison shower block. The same prisoner who had provided the deceased with the cleaning product earlier, went to the shower black around the same time as the deceased. She heard noises and became concerned for the deceased’s welfare. Prison staff were alerted and attended the shower block.

The deceased was located inside a shower cubicle hanging with a cloth ligature around her neck. Prison and medical staff attempted resuscitation but were unsuccessful and the deceased was declared life extinct.

The Coroner made two recommendations relating to improving the mental health resources at Bandyup Women’s Prison. The third recommendation was made to allow medical and nursing staff who are treating remand and sentenced prisoners, information which will assist them to provide a better level of care and treatment.

Catch Words : Death in custody; Mental Health Care in Women’s Prison ; Female Only forensic mental health unit; suicide.


Last updated: 7-Oct-2019

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