Coroner's Court of Western Australia

Inquest into the Death of Shane Nathan ROBERTS

Inquest into the Death of Shane Nathan ROBERTS

Delivered on : 21 December 2023

Delivered at : Perth

Finding of : Coroner Urquhart

Recommendations : Yes

Recommendation No. 1

In order to improve the standard of health care to prisoners, the Department of Justice undertakes an assessment of employment contracts for prison heath service providers to determine whether changes can be made that would:

  1. encourage health service providers to remain working in the prison system; and
  2. provide a motivation for suitably qualified health service providers to apply for positions within the prison system.

Recommendation No. 2

In order to provide an appropriate level of mental health care and treatment for prisoners at Hakea, the Department of Justice should take urgent steps to recruit additional Psychological Health Service and mental health staff for Hakea.

Recommendation No. 3

In order to provide an appropriate level of health care and treatment for prisoners in Hakea, urgent funding be provided for a project definition plan regarding an extension of the facilities at Hakea that are used to provide health care (including counselling and mental health care) to prisoners.

Orders/Rules : N/A

Suppression Order : N/A

Summary : On 24 June 2019, Shane Nathan Roberts (Mr Roberts), who was a remand prisoner at Hakea Prison (Hakea) was found inside his cell with a ligature around his neck. Despite resuscitation efforts, Mr Roberts could not be revived. He was 41 years old.

As Mr Roberts was a person held in 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 custody. The inquest focused on the treatment and care Mr Roberts received for his mental health issues.

After being changed with some serious offences, Mr Roberts was remanded in custody at Hakea on 27 February 2019. At his initial assessment, it was considered he was at a high risk of self-harm and/or suicide. He was subsequently placed on the Department’s primary suicide prevention strategy (ARMS) and under the management of the Prisoner Risk Assessment Group (PRAG). He remained on ARMS until 13 March 2019.

On 7 May 2019, Mr Roberts saw a prison doctor complaining of anxiety and depression. His anti-depressant medication was increased and the prison doctor referred him to the Mental Health Team at Hakea (the MHT). On 13 and 25 May 2019, Mr Roberts made written requests for a medical appointment, stating that his anxiety was getting worse and the increase in his medication had not helped. Although nurse appointments were made for Mr Roberts on 16 and 21 May 20219, he did not attend either appointment. When he did not attend the second appointment, a nurse with the MHT listed Mr Roberts to be discussed at the MHT weekly meeting on 17 June 2019.  At that meeting, a decision was made to refer Mr Roberts back to the prison doctor for further treatment. An appointment with the prison doctor had not been scheduled before Mr Roberts’ death on 24 June 2019.

The Coroner was satisfied with the treatment and care provided to Mr Roberts with respect to his mental health concerns up to 7 May 2019. However, the treatment and care of Mr Roberts’ mental health issues was not satisfactory from that date to when he took his life seven weeks later. The Coroner found that this sub-optimal care was due to the inadequate resources available to mental health service providers at Hakea who had done their best with what they had to treat the large cohort of prisoners with significant mental health issues.  

The Coroner made three recommendations designed to deliver better health care, particularly mental health care, to prisoners in Hakea.

Catch Words : Death in Custody : Supervision, Treatment and Care : Suicide: Mental Health Care at Hakea


Last updated: 10-Jan-2024

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