Coroner's Court of Western Australia

Inquest into the Death of Matthew Francis LEACH

Inquest into the Death of Matthew Francis LEACH

Delivered on : August 2024

Delivered at : Perth

Finding of : Deputy State Coroner Linton

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : In December 2021, Matthew Leach was a remand prisoner at Hakea Prison. He had earlier been identified as a ‘prisoner at risk’ and had been monitored by Hakea Prison Psychological Services staff. However, by late October 2021, he appeared to have settled and monitoring was ceased.

On 20 December 2021, Mr Leach appeared by video link from Hakea Prison before a magistrate in the Fremantle Magistrates Court. He was found guilty of a number of charges, including violent offences against his former partner, and was sentenced to a total term of 12 months’ imprisonment. This court date had not been recorded as a ‘date of interest’ for Mr Leach and he was not subject to formal monitoring, so he was not reviewed by prison staff before he returned to his cell. On his return to his cell, Mr Leach’s cell mate noticed he seemed a little withdrawn, although Mr Leach indicated he was okay.

After the lunch lockdown, Mr Leach made a phone call to his father. His father did not answer the call, so Mr Leach left a message on his father’s answering service at 1.32 pm. In the message, he indicated he was contemplating suicide. The message was not received by his father until later, and the call was not monitored, so no alert was raised. Mr Leach returned to his cell. His cell mate had gone to another unit, so Mr Leach was in his cell alone. Prison officers were conducting a routine check of cells at around 2.23 pm when they opened Mr Leach’s cell door and found him hanging on the back of the cell door with a ligature made from a bed sheet and inserted between the door and the door frame. Mr Leach’s unresponsive body fell to the ground when the door opened and released the ligature. The prison officers alerted other staff while another prisoner assisted to release the ligature. Prison staff then commenced CPR, which was continued by SJA officers on arrival at the prison. Before being placed in an ambulance, SJA officers conducted a full assessment of Mr Leach and determined that further resuscitation efforts were futile. His death was declared at the prison by a paramedic at 3.17pm.

As Mr Leach was a prisoner at the time of his death, an inquest was mandatory. At the conclusion of the inquest, the Coroner found the cause of death was ligature compression of the neck (hanging) and Mr Leach died by way of suicide.

The Coroner was required to comment on the treatment, supervision and care provided to Mr Leach prior to his death, as Mr Leach was a person’ held in care’ at the time of his death. The Coroner noted that previous recommendations by coroners in other similar inquests were relevant to this inquest.

Catch Words : Suicide : Hanging : Death in Custody : Hakea Prison ; Dates of Interest; Resuscitation Protocols.

 


Last updated: 20-Sep-2024

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