Coroner's Court of Western Australia

Inquest into the Death of Khamsani Victor JACKAMARRA (also known as Hajinoor)

Inquest into the Death of Khamsani Victor JACKAMARRA (also known as Hajinoor)

Delivered on : 9 May 2019

Delivered at : Perth

Finding of : Deputy State Coroner Vicker

Recommendations :Yes

Recommendation 1

Retain and ensure B(R)P has appropriate services which acknowledge it is a major transition facility with all the known risks that raises.

Recommendation 2

Information sharing between medical, PCS and mental health services in prison and appropriate sharing of information between custodial facilities and organisations in the community caring for those with mental health issues.

Recommendation 3

Effective CCTV and practical ligature minimisation. I am not suggesting CCTV directly into toilet or shower facilities, but good coverage on adjacent points may avoid issues to do with welfare. It is a sad fact that rarely in inquests are all relevant CCRTV monitors operational.

Recommendation 4

Prison officer training that those with prior suicide attempts are at elevated risk in custody regardless of their demeanour.

Recommendation 5

The promotion of active involvement of prisoners in caring for one another.

Recommendation 6

Realisation on behalf of custodial services that welfare and security go hand in hand. I appreciate that prisons are involved in security on behalf of the community, but destabilised prison populations due to successful suicides are distressing for all concerned, staff and other prisoners, and can rapidly become a security issue of itself.

Orders/Rules : N/A

Suppression Order : N/A

Summary : The deceased at the time of his death was in the care of the Department of Justice pending the signing of the surety papers for his bail undertaking. The deceased was a 36 year old Aboriginal male.

The deceased had a significant criminal history with offences of considerable violence, mostly against women. The majority of his offending reflected his use of alcohol and illicit substances, and when not intoxicated he expressed a desire not to be violent. His substance misuse coincided with a significant history of mental health issues in the form of personality disorders for which he was prescribed medication but with which he was not always compliant. The deceased had been a long term client of the mental health services in the Kimberley.

On 16 December 2015 the deceased, who had not made prior arrangements for his surety to be available at his court appearance that morning, was remanded by the Court for sentence with bail and a surety. Significant attempts were made by various people during the course of the morning to enable the deceased’s surety to be signed, but these attempts were unsuccessful. Once the deceased realised he would remain in custody he became withdrawn and then frustrated.

The deceased was transferred from the Broome Magistrates Court to the Broome Regional Prison and into the prison system without effective communication of his behaviour pending transfer. He was assessed and prison officers had no concerns regarding the deceased’s welfare or state of mind. The deceased spoke with a prison support officer and while he appeared to be upset initially, by the time they finished speaking the prison support officer had no concerns for his welfare. After this meeting a prison officer met with the deceased and they went through the orientation check list. The deceased was seen to interact with other prisoners and he had chosen the cell in which he wished to stay in. Another prisoner wished to say hello to the deceased and was told he was in the shower block. He did not go and find him.

The deceased was found by a fellow prisoner in the shower block, which was old and with accessible hanging points. The deceased had used a shirt to hang himself in the shower sometime during the 40 minutes since he had spoken with the prison officer, about having a telephone assisted call to his family.

The Coroner found that even with proper communication of the deceased’s behaviour while at the Broome Court House, and knowledge of his prior attempts at self harm while in custody, the conditions and systems in place in Broome Prison at that time would not have made a difference to how the deceased was dealt with in the two and half hours he was present in the prison.

The Coroner made six recommendations relating to improving well-being and minimisation of the risks associated with prisoners suffering from mental health.

Catch Words : Risk Minimisation in Custody : Mental Health Services : Training : Suicide

Last updated: 29-May-2019

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