Inquest into the Death of Brett Ashley DUTURBURE

Inquest into the Death of Brett Ashley DUTURBURE

Delivered on :22 December 2021

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : Yes

When a prisoner is first received at a prison in Western Australia, the prisoner should be asked whether they have ever been incarcerated in another State or Territory prison.

Where a prisoner discloses having been incarcerated in another State or Territory prison the, as soon as is practicable, the Department should obtain records relating to that intestate incarceration (including medical records) in order to ensure that the prisoner is appropriately managed.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Duturbure died on or about 14 November 2019, from ligature compression of the neck at the Wyndham Work Camp (WWC), where he was a sentenced prisoner.  He was 29-years or age.

Mr Duturbure was admitted to Broome Regional Prison (BRP) on 12 August 2017.  During his intake assessment he denied previous or current self-harm or suicidal ideation.  Although Mr Duturbure told the intake officer at BRP that he had been incarcerated at Darwin Prison (DP) in the Northern Territory, no attempt was made to obtain records relating to that incarceration.  Records obtained from DP and the Ryal Darwin Hospital, after Mr Durturbure’s death, disclosed that he had threatened self-harm in 2005 and attempted to take his life in 2007 and 2010.

At his request, Mr Duturbure was transferred to West Kimberley Regional Prison (WKRP) so he could visit his partner who was also imprisoned at the WKRP.  On 28 August 2017, Mr Duturbure was seen by the Prison Counselling Service (PCS) and denied any previous or current self-harm or suicidal ideation.  WKRP records indicate Mr Duturbure maintained regular employment and completed educational and vocational training.  He received visits from his partner and was in regular phone contact with his family.

On 5 September 2019, Mr Duturbure referred himself to PCS.  He subsequently attended several counselling sessions, during which he disclosed issues relating to his childhood, anger management and relationship difficulties with his partner.  On 1 October 2019, Mr Duturbure discontinued counselling and requested a transfer to the WWC.  His request was granted and Mr Duturbure arrived at WWC on 18 October 2019.

On the evening of 13 November 2019, Mr Duturbure was sitting on the veranda of his unit talking and interacting with others and was last seen alive during the evening muster at 10.00 pm.  At 5.00 am on 14 November 2019, a fellow prisoner found Mr Duturbure hanging from a tree with a garden hose around his neck.  Prison officers were alerted and cut Mr Duturbure down before sting CPR and calling emergency services.  Ambulance officers arrived and took over resuscitation efforts, but Mr Duturbure could not be revived.

The Coroner concluded the quality of medical care provided to Mr Duturbure while in custody was commensurate with the standard of care he would have received in the general community.  However the Coroner found that the failure by the Department of Justice to obtain records relating to Mr Duturbure’s incarceration in DP (and thereby discover his previous self-harm and suicidal ideation history) meant that the quality of supervision, treatment and care provided to Mr Duturbure during his incarceration was potentially of a lower standard than might otherwise have been the case.  In light of his observations, the Coroner made one recommendation relating to obtaining interstate prison records.

Catch Words : Death in Custody : Quality of Supervision, Treatment and Care : Records from Interstate : Suicide


Last updated: 6-Apr-2022

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