Coroner's Court of Western Australia

Inquest into the Death of Phillip John ALLEN

Inquest into the Death of Phillip John ALLEN

Delivered on :6 February 2024

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : N/A

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 29 July 2020, Phillip John Allen (Mr Allen), a prisoner at Roebourne Regional Prison (RRP), was found inside the toilet cubicle of his cell with a ligature around his neck. Despite resuscitation efforts by custodial staff, Mr Allen could not be revived. He was 47 years old.

As Mr Allen was a person held in the care of the CEO of the Department of Justice (the Department), an inquest into his death was mandatory to examine the quality of his supervision, treatment and care when he was in RRP. The inquest focused on the treatment and care provided to Mr Allen with respect to his mental health, and the supervision of him on the night of his death.

After being charged with some serious offences, Mr Allen was remanded in custody at RRP on 27 February 2020 and remained there until his death.

Shortly after he had been placed in RRP, Mr Allen began complaining about “black magic”. By 17 April 2020, Mr Allen’s cell mates had advised custodial staff that he was behaving strangely and talking about spirits. On 6 May 2020, after receiving a report that he was contemplating self-harm, Mr Allen was placed on the Department’s primary suicide prevention strategy (ARMS) under the management of PRAG (the Prisoner Risk Assessment Group). On 7 May 2020, following a risk  assessment, Mr Allen was removed from ARMS and placed on SAMS (Support and Monitoring System), which is a step down from ARMS.

Mr Allen’s behaviour continued to escalate and he complained he had been “sung”. Although Mr Allen denied thoughts of self-harm or suicidal ideation during regular contact with prison mental health service providers and the Prison Support Officer, treatment of his mental health issues was complicated by his refusal to take medication for these issues. Following an appointment with Mr Allen on 15 July 2020, the  prison psychiatrist noted he had an apparent delusional disorder and that cultural counselling may be beneficial to address apparent spiritual issues.

On the night of 28 and 29 July 2020, Mr Allen was housed in a six bed cell in Unit 2. Three nightly cell and body checks were required for each cell at RRP following the lock-up of cells and before the unlocking of cells the following morning. Although Mr Allen was sighted by a prison officer when she conducted the second cell and body check at about 11.10 pm, she failed to satisfy herself that all the prisoners were accounted for inside Mr Allen’s cell when she conducted the final cell and body check at about 4.35 am.

In between the second and third cell and body checks, Mr Allen entered the cell’s toilet cubicle, locked the toilet door and hanged himself from one of a number of diagonal metal grilles that were in front of the cubicle’s window. He was not discovered by prison officers until the cell was unlocked at about 6.35 am on 29 July 2020.

The Coroner was satisfied that the mental health care Mr Allen received in RRP was appropriate given the resources available to mental health service providers and the COVID-19 restrictions that were in place for much of Mr Allen’s imprisonment. The Coroner was also satisfied that Mr Allen’s suicide was unexpected and would have been difficult to predict.

However, the Coroner was not satisfied that the supervision of Mr Allen during the final cell and body check on 29 July 2020 was adequate. The Coroner was also satisfied that there was an inaccurate entry in the occurrence book by another prison officer who knew it misleadingly indicated that a body count had been done in all cells at Unit 2 during the final cell and body check. 

The Coroner noted that since Mr Allen’s death, measures had been taken by the Department to cover the diagonal metal grilles in front of toilet cubicle windows in cells. The Coroner also noted that similar grilles in front of windows in the common areas of cells are to be covered when air-conditioning is installed in these cells. This installation is scheduled to commence in mid-2024. In those circumstances, the Coroner did not consider it was necessary to make a recommendation that these obvious ligature points be rendered inaccessible to prisoners when they are in their cells.

Catch Words : Death in Custody : Supervision, Treatment and Care: Suicide: Mental Health Care: Reduction of Ligature Points

Last updated: 19-Feb-2024

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