Coroner's Court of Western Australia

Inquest into the Death of Jayden Stafford BENNELL

Inquest into the Death of Jayden Stafford BENNELL

Delivered on :28 February 2017

Delivered at : Perth

Finding of : Coroner Linton

Recommendations :Yes

I recommend that the Department of Corrective Services, when planning what future changes are to be made to the mental health services it provides to prisoners, should invest significantly more resources in ensuring that prisoners are given regular access to psychiatrists and that overall an emphasis be placed on providing a more holistic approach to mental health care. Efforts should be made where possible to hire some Aboriginal mental health workers to form part of the mental health team.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased was a young Aboriginal man who hanged himself while serving a sentence at Casuarina Prison. He was 20 years old.  At the time of his death he wasa  person held in care, therefore, pursuant to section 22(1)(a) of the Coroners Act 1996 it is mandatory to hold an inquest into his death.

The issues which were explored at the inquest hearing were primarily the psychiatric care provided to the deceased while a prisoner within the custodial environment and issues relating to his ability to freely access the cupboard where he died, which had not been subject to the Department’s ligature minimisation program. The issue of adequacy of the supervision on the afternoon of the deceased’s death was also explored, as well as the adequacy of the investigation into the deceased’s death.

The deceased was known to the Department of Corrective Services to be a person who had a history of psychiatric illness. While the deceased was on remand at Hakea Prison he was in the care of a Consultant Psychiatrist.  After a while the deceased became non-compliant with taking his medications; however, mental health reviews continued and it was noted that although the deceased had refused to take medications, it appeared his mental state was showing signs of improvement.

On 26 November 2012 the deceased was transferred from Hakea Prison to Casuarina Prison. Upon arrival at Casuarina Prison the deceased maintained his refusal of medication despite those medications being prescribed and offered to him.  The deceased continued to be reviewed and agreed to see a psychiatrist to discuss formally ceasing his medications, but that appointment did not eventuate.  However, the deceased was reviewed by a mental health nurse on 25 February 2013 who did not note any change in his presentation.  This was the deceased’s last mental health appointment prior to his death.

On the morning of his death the deceased appeared to be his usual self. The deceased attended the medication round under escort by prison officers, but he refused to take it.  He then attended the Pathways Program (High Intensity Addictions Course) which concluded at 11:20am.  He returned to his unit sometime prior to the lunchtime muster.  The deceased was recorded at the lunchtime muster at his unit.  He was locked alone in his cell for the lunchtime period.  The deceased was then seen outside his cell during the muster head count and appeared normal.  The deceased did not attend the afternoon session of the Pathways program.  Telephone records show that he attempted to make a telephone call at 1:26pm.  This is the last time that the deceased is known to have been alive.

The deceased was missing from the afternoon muster head count and a second muster was called. It was during this second muster the deceased was located in the cleaning storeroom with a ligature around his neck.  A code red was called and a number of nurses from the health centre attended.  Prison officers had started to commence CPR.  A defibrillator was applied which showed that he was asystole.  The prison doctor attended and gave the deceased two doses of adrenaline.  St John Ambulance paramedics attended the unit but the deceased was still asystole upon their attendance.  Paramedics administered further adrenaline and continued CPR for a further twenty minutes before he was declared life extinct.  Police officers from the Forensic Field Operations – Crime Scene Investigations unit attended and examined the deceased and commenced their investigations.

The Coroner accepted the evidence of two psychiatrists that it could not be said that if the deceased had seen a psychiatrist it would necessarily have altered the path of events. However, the Coroner accepted that the failure to give the deceased access to a psychiatrist at Casuarina was relevant as it may have enabled the psychiatrist to assess his mental state and associated risk of self-harm.  The Coroner also accepted that since the deceased’s death, there has been an improvement of the availability of psychiatrists at Casuarina, but noted that on the whole, mental health treatment in WA prisons remains under resourced and underfunded.  In this context, the Coroner made the recommendation in the hope that these failings in this death, are taken into account by the Department for the future.

The Coroner also acknowledged that unsupervised access to the cleaning storeroom was now limited to a period in the morning.

The Coroner concluded the deceased died on 6 March 2013 at Casuarina Prison as a result of ligature compression of the neck (hanging) and found that the manner of death was by way of suicide.

Catch Words : Death in Custody : Quality of Supervision, Treatment and Care : Ligature Minimisation Program : Mental Health Facilities : Ligature Compression of the Neck (Hanging) : Suicide.

Last updated: 30-Apr-2019

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