Coroner's Court of Western Australia

Inquest into the Death of Jomen BLANKET

Inquest into the Death of Jomen BLANKET

Delivered on : 21 August 2023

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : Yes

Recommendation No. 1

In order to provide appropriate care and treatment for prisoners in Acacia, funding be provided as a matter of urgency for a project definition plan regarding the creation of a therapeutic care unit to treat mentally unwell prisoners (including prisoners who are deemed to be at a high risk of self-harm) who do not meet the criteria for an involuntary admission to an authorised hospital under the Mental Health Act 2014 (WA).

Recommendation No. 2

To address the previous inequality for access to treatment programs between prisoners who have been assessed for an IMP and those who have not, the Department’s pilot Parole-in-reach Program (PiP) involving AOD and FDV criminogenic programs for short-term prisoners who are ineligible for IMPs be fully implemented and made available to the general prison population.

Recommendation No. 3

To enhance the care of vulnerable prisoners, a person from the prison’s health service that provides psychological and counselling support be on standby should it be suspected that a prisoner may require such support after being informed of a decision from the Prisoner Review Board regarding the prisoner’s parole eligibility. Preferably, this person should be one who is known to the prisoner.

Recommendation No. 4

So that there is compliance with section 7.5 of the ARMS Manual, Serco is to ensure that the chairperson of PRAG at Acacia is aware that a prisoner on ARMS must be invited to attend their case review, unless it is not in the prisoner’s interests to do so.


The Department is to also take appropriate measures to ensure that case reviews at PRAG meetings in other prisons are complying with this part of section 7.5 of the ARMS Manual relating to the attendance of prisoners at their case reviews.

Recommendation No. 5

To overcome reluctance from a prisoner to attend their PRAG case review, a provision is added to section 7.5 of the ARMS Manual entitling a prisoner who is attending their case review to have a suitable support person accompany them. 

Recommendation No. 6

To assist with the timely care and treatment of mentally unwell prisoners, a prison’s after-hours health service providers and chairperson of PRAG have access to the mobile telephone numbers of the prison’s mental health service providers if urgent and immediate contact is required regarding the mental welfare of a prisoner.

Recommendation No. 7

If the Department’s Review of a Death in Custody at Acacia accepts any of the findings and/or recommendations made in Serco’s Post Incident Review of the death, then the Department’s Review should clearly identify that acceptance.

Orders/Rules : N/A

Suppression Order : N/A

Summary : Mr Blanket died on 12 June 2019 at Acacia Prison (Acacia). He was a 30-year-old First Nations man. As he was a sentenced prisoner when he died, Mr Blanket’s death was the subject of a mandatory inquest that examined the quality of his supervision, treatment and care when he was in custody. 

Mr Blanket commenced a 12-month term of imprisonment on 23 October 2018. This was the first time Mr Blanket had been imprisoned.  On 6 November 2018, he was transferred to Acacia. 

Throughout his imprisonment, Mr Blanket struggled with his mental health and cultural beliefs. He self-harmed and expressed suicidal ideation on a number of occasions which had him regularly placed on the Department of Justice’s primary suicide prevention strategy (ARMS) and under the management of Acacia’s PRAG (the Prisoner Risk Assessment Group). He was often placed in a ligature-free safe cell so he could be closely monitored when he was considered to be at high risk.  

On 22 April 2019, Mr Blanket was advised that he had been denied eligibility for parole. That had a significant impact on his mental wellbeing. On that same day, he assaulted two other prisoners and attempted to hang himself using a torn bedsheet which he had knotted at one end to provide an anchor point with his closed cell door. He showed prison officers the torn bedsheet and explained how he had tried to hang himself.

On 10 May 2019, Mr Blanket met briefly with the prison psychiatrist who formed a view that he had an evident psychotic illness in its early stages that had been preceded by affective depressive symptoms. At a second appointment with the psychiatrist on 30 May 2029, Mr Blanket declined to take any antipsychotic medications. He had also stopped taking the antidepressant medication that had previously been prescribed by the prison doctor. 

On the morning of 12 June 2019, a prison officer noticed Mr Blanket appearing distressed. As this was a component of Mr Blanket’s risk management plan, the prison officer raised her concerns with the PRAG chairperson. A decision was made by the PRAG chairperson that Mr Blanket should be relocated to a ligature-free safe cell due to the heightened risk of self-harm. Although such a relocation ordinarily took 10 to 15 minutes, on this occasion there was a delay. During that delay, Mr Blanket moved from the common area of the unit he was housed in to his one-person cell. After entering his cell, he closed the door and locked it from the inside.    

At about 10.10 am, the prison officer who had earlier noticed Mr Blanket’s distressed state decided to check on him in his cell. When she found the door to be prisoner-locked from the inside, she unlocked it. As she opened the door, she observed Mr Blanket unresponsive against the inside of the door with a torn bedsheet around his neck. Despite repeated attempts to resuscitate him, Mr Blanket could not be revived.   

A forensic pathologist identified the cause of Mr Blanket’s death as ligature compression of the neck (hanging) and the Coroner determined that the manner of death was suicide. The Coroner also formed the view that Mr Blanket had used the same method he had described to prison officers in April 2029 and to a prison social worker on 14 May 2029.  

The Coroner was generally satisfied with the treatment and care provided to Mr Blanket by the mental health service providers at Acacia.

However, although it was appropriate to allow Mr Blanket to enter his cell on the morning of 12 June 2029, Acacia staff should not have permitted him to close his cell door. It meant Mr Blanket was not adequately supervised, and he had the opportunity and the means to implement his known suicide plan at a time when he was at an elevated risk of self-harm. The Coroner was also critical of the inadequate number of safe cells at Acacia which meant there was a delay in relocating Mr Blanket to such a cell on the morning he died.

The Coroner found that both these issues were contributory factors in Mr Blanket’s death.

The Corner made a number of recommendations designed to deliver better mental health care to prisoners and to give short-term prisoners greater opportunities to complete treatment programs that will enhance their prospects for parole.

Catch Words : Mandatory Inquest: Death in Custody: Suicide: Mental Health Care at Acacia: Supervision 

Last updated: 30-Aug-2023

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