Coroner's Court of Western Australia

Inquest into the Death of Jordan Robert ANDERSON

Inquest into the Death of Jordan Robert ANDERSON


Delivered on : 22 December 2020

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : Yes

Recommendation 1

As a matter of urgency, the Department should consider increasing the number of ligature minimised cells at Hakea Prison with a view to having all cells at Hakea Prison either fully ligature minimised or three-point ligature minimised as soon as possible.

Recommendation 2

In order to better manage prisoners and thereby enhance security at Hakea Prison, the Department should increase the number of safe cells from six to 12.

Recommendation 3

A suitably qualified prison mental health staff member should conduct a mental health assessment as soon as it is practicable upon any prisoner who has been involved in a critical incident regarding violent behaviour or who has been the subject of punishment requiring placement in a specialised unit for disciplinary purposes.

Recommendation 4

In order to ensure that prison officers are better equipped to deal with situations where prisoners attempt to take their lives by way of hanging, officers should participate in drills involving simulated hanging scenarios during their initial employment training and during refresher training for CPR.

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 23 March 2017 at Fiona Stanley Hospital Mr Anderson died from complications of ligature compression of the neck. At the time of his death Mr Anderson was on remand at Hakea Prison and placed in a specialised unit for disciplinary reasons. He was 23 years old.

A prisoner who had a cell opposite to Mr Anderson’s cell spoke to Mr Anderson on the evening of 4 March 2017. Mr Anderson told him about an upsetting phone call and a visit he was expecting not taking place. Mr Anderson did not indicate he may self-harm. At a cell check at 10.00 pm that night Mr Anderson was in his cell on his bed and appeared to be asleep. The next check was after midnight on 5 March 2017 and Mr Anderson was noted not to be on the bed. A torch was used to scan the cell and a sheet tied to the single tap located on the right hand side of the cell’s basin was noted. After unlocking the medical hatch of the cell door Mr Anderson was seen to be sitting on the floor near the basin with the sheet tied around his neck. Mr Anderson did not respond and was not moving.

Assistance was called for immediately and a Code Red medical emergency was deployed. However, Mr Anderson’s cell door was not unlocked until approximately 3 minutes and 40 seconds after the Code Red alert was made. More prison officers came to assist including medical staff. A defibrillator was used but did not register any rhythm; however, CPR was not commenced until nearly 10 minutes after Mr Anderson was not seen on his bed. An Ambulance was called for and attended the prison. Ambulance officers were successful in establishing a pulse and Mr Anderson was conveyed by ambulance to Fiona Stanley Hospital. Mr Anderson was placed on artificial respirator and despite ongoing supportive care Mr Anderson continued to deteriorate until his death on 23 March 2017.

The Coroner made four recommendations aimed at minimising ligature points in cells at Hakea Prison, increasing the number of safe cells at Hakea Prison, conducting mental health assessments with misbehaving prisoners and improving prison officer training.

The Coroner was reasonably satisfied the Department of Justice provided adequate supervision, treatment and care to Mr Anderson throughout his five periods of incarceration, except for the failure by prison staff to unlock his door and then commence CPR within a reasonable time frame on 5 March 2017.

The Coroner found Mr Anderson’s death occurred by way of suicide.

Catch Words : Death in Custody : First Aid Training for Prison Officers : Delay in providing CPR : Ligature minimised cells : Recommendations : Suicide

Last updated: 22-Mar-2022

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