Coronial Inquest into the death of
Delivered on: 22 May 2019
Delivered at: Perth
Finding of: Coroner Jenkin
Suppression Order: N/A
Summary: At the time of all their respective deaths, the five deceased persons were prisoners in the custody of the Chief Executive Officer of the Department of Corrective Services, as it was then was.
Pursuant to a direction by the State Coroner on 25 February 2019, all five deaths were investigated at one inquest. That inquest focused on the supervision, treatment and care provided to each of the deceased persons while they were prisoners, as well as the circumstances of their respective deaths.
The Coroner found that that each of the deceased persons had died at Casuarina Prison and that the cause of death in each case was suicide. The Coroner heard evidence about the management of at risk prisoners, some of the risk factors impacting on prisoner management and the strategies and tools employed to address those factors.
The Coroner made eight recommendations relating to improving prisoner welfare and enhancing the security of Casuarina Prison.
Catch Words: Deaths in Custody : Mental Health Issues : Gatekeeper and Mental Health : Training : Prisoner Risk Assessment : Ligature Minimisation : Use of Technology : Suicide