Coroner's Court of Western Australia

Inquest into the Death of Gerardus Gerritt HEIJNE

Inquest into the Death of Gerardus Gerritt HEIJNE

Delivered on :7 October 2016

Delivered at : Perth

Finding of : Deputy State Coroner

Recommendations :Yes

I recommend telephone calls recorded prior to the death of a prisoner in custody be provided to the Coroners Court as they were in the past. All prison deaths are mandated to be inquested, and while I appreciate not all telephone calls, although recorded are listened to within the prison system, nor is it feasible, they may provide some insight, post the event, as to what may have been in operation in the prisoner’s mind at the time.  This may indicate strategies which may be of use in the future in preventing some suicides.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was a sentenced prisoner serving a substantial prison term of imprisonment for murder and was a person held in care. At the time of his death the deceased was in the self-care unit at Acacia Prison and was healthy and fit, he was 49 years of age.

On the morning of 26 March 2013 the deceased was located by a fellow prison inmate, hanging from his locked cell door by a dog leash the deceased had secure to the outer door handle, following unlock earlier that morning.

While in prison the deceased undertook to further his education in business and related studies as well as applying for a number of short term courses useful for general living. The deceased formed an emotional attachment and became engaged towards the end of 2009.  The deceased was assessed for his suitability to participate in cognitive skills and violent offending programs for which he received extensive assessment in February 2011.  The deceased appears to have adapted to life as an inmate well.  He lived in a self-are pod.

There were difficulties for the deceased within the prison system due to the perception he was financially secure in his external life. Prisoners do not have access to bank accounts, other than the prisoner spends while incarcerated.  This may have caused the deceased difficulties as a result of pressure within the system with requests for loans.  Some concerns with respect to the deceased’s external financial holdings were canvased with him in February 2013, however, he denied there were any issues.

The Coroner concluded on the whole of the evidence, the deceased’s suicide was reasonably premeditated and not an impulsive act, and that risk factors were present which would account for his decision.

The deceased had regular contact with his finance using the prison telephone access to specified numbers. These calls between the deceased and his fiancé were accessed following the deceased’s death which indicated the deceased was concerned about a financial transaction external to the prison but connected to the fact of his incarceration, in the days before his death.  He was discussing ways of dealing with complications which had arisen immediately prior to his death.  In hindsight, it is clear the deceased was suffering stress with respect to the manner in which he intended to deal with those complications.

The Coroner found that with the provision of the deceased’s telephone calls and review of the very competent assessments of the deceased by the prison system, it was possible to understand the deceased’s denial strategies for coping with stressors he experienced. In this context the Coroner made a recommendation in respect to the mandatory provision of telephone calls should be provided to the Coroners Court.

The Coroner found the deceased died on 26 March 2013 at Acacia Prison as a result of ligature compression of the neck and death occurred by way of suicide.

Catch Words : Death in Custody : Prisoner Mental Health : Suicide


Last updated: 4-Jul-2024

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