Coroner's Court of Western Australia

Inquest into the Death of Stanley John INMAN

Inquest into the Death of Stanley John INMAN

Delivered on :19 July 2023

Delivered at : Perth

Finding of : Coroner Jenkin

Recommendations : No

Orders/Rules : No

Suppression Order : N/A

Summary : Mr Stanley John Inman (Mr Inman) was 19-years of age when he died at St John of God Midland Hospital (SJOG) on 13 July 2020, from complications of ligature compression of the neck.

At the time of his death Mr Inman was a sentenced prisoner at Acacia Prison (Acacia), having been received there on 19 February 2020.  During the reception process, Mr Inman disclosed a previous attempt to take his life, and his history of rheumatic heart disease (which required monthly injections of benzylpenicillin) was noted.

From 4 to 8 July 2020, Mr Inman made numerous phone calls to his mother, and his partner and in a number of these calls he expressed suicidal ideation.  On 8 July 2020, Mr Inman told staff he had been self-harming by cutting himself.  He was placed on the At Risk Management System (ARMS) on hourly observations, and moved to an observation cell.

On 9 July 2020 Mr Inman was seen by a psychologist, and he denied suicidal or self-harm ideation.  Prison authorities were unaware of the content of the phone calls Mr Inman had been making, and he said he wanted to be returned to his prison unit, where he had strong “family support”, and that he regretted his self-harming behaviour.  The psychologist recommended Mr Inman’s ARMS observations be reduced from “high” to “medium”, and this recommendation was endorsed by the Prisoner Risk Assessment Group (PRAG) that meets to discuss all prisoners being managed on ARMS.

On 10 July 2020, Mr Inman was reviewed by another psychologist, and although he had a “flat affect”, he again denied suicidal or self-harm ideation, and expressed regret at his recent self-harm.  Mr Inman said he wanted to be transferred temporarily to Albany Regional Prison temporarily to visit family, and was keen to return to his prison unit.  The psychologist recommended Mr Inman’s ARMS observations be reduced from “medium” to “low and that he be returned to his unit.  This recommendation was endorsed by the PRAG, and Mr Inman was returned to his unit on low ARMS.

After returning to his unit, Mr Inman called his partner numerous times, but his calls were not answered, and he also called his mother and told her not to come in the following day for a scheduled visit.  On 11 July 2020, Mr Inman seemed to be fine according to his cellmate, and he was seen interacting with other prisoners and playing a computer game.  Mr Inman called his partner four times, but his calls were not answered because she had been taken into custody the day before.  At 10.36 am, Mr Inman also called his mother and when he said he was going, she asked him asked him if he was going to “do anything stupid”, and he replied: “I’m not”, before ending the call.

During the lunch-time muster at about 11.20 am, Mr Inman was not standing outside his cell as he was required to do.  A search was instituted, and Mr Inman was found hanging in a storeroom in his unit, with a rope around his neck that was tied to an air conditioning unit.  The ligature was removed and prison officers started CPR, before ambulance officers arrived and took Mr Inman to SJOG.

Over the next two days, Mr Inman’s condition deteriorated, and he was declared deceased at 10.54 am on 13 July 2023.

The Coroner concluded that although that the management of Mr Inman’s general health was appropriate, the overall quality of Mr Inman’s supervision, treatment and care was of a lower standard than it should have been because his level of risk was not properly understood.  This occurred this occurred because Mr Inman’s background risk level was not properly appreciated when he was first admitted to prison, and because the content of the calls he had been making in the days before his death, was not assessed at the PRAG meetings discussing his level of risk.

The coroner noted that whilst there is no guarantee that Mr Inman’s life journey would have been different if he had been the subject of greater scrutiny for longer, had the PRAG had access to the content of the phone he had been making, he would have been provided with a greater level of support.  The coroner also noted that since Mr Inman’s death Since Mr Inman’s death, the phone calls and mail of those prisoners who are on ARMS is now the subject of some level of scrutiny.  In addition, and the previously unfettered access by prisoners to storerooms in their units has now been removed.

Catch Words : Death in Custody : Assessment of Risk : Monitoring of phone calls made by at risk prisoners : Suicide

Last updated: 21-Nov-2023

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