Coronial Inquest into the death of Bret Lindsay CAPPER
Delivered on: 13 November 2019
Delivered at: Perth
Finding of: Coroner Jenkin
Suppression Order: N/A
Summary: Until shortly before his death, the deceased was being held in custody on remand at Hakea Prison. He died on 14 January 2016 at Fiona Stanley Hospital as a result of bronchopneumonia and brain swelling following ligature compression of the neck (hanging). He was 43 years of age.
On 12 January 2016, the deceased had barricaded himself into a communal area in the prison wing he was being housed in. Despite the efforts of prison officers, the deceased placed an improvised ligature around his neck and hanged himself. He had told other prisoners and custodial staff that he could not face the long prison sentence he anticipated he would receive.
Officers for the Special Operations Group (SOG) were deployed to Hakea Prison and used specialist equipment to gain access to room where the deceased was located. The deceased was given first aid and transported to Fiona Stanley Hospital.
The deceased had sought counselling for his mental state on 30 October 2015, but because there were not enough counsellors at Hakea Prison at the time, he was seen on only one occasion. The deceased had previously been diagnosed with antisocial personality disorder and the evidence at the inquest was that he would have benefitted from long-term counselling, had this been available. The Coroner found that the deceased was not placed on the Prisonâ€™s Support and Monitoring system after being removed from At Risk Management System on 20Â October 2015. Had this occurred, the deceased would have been monitored more regularly by the Prison At Risk Management Group and may have been more likely to have received ongoing counselling.
Since the deceasedâ€™s death, physical changes have been made at Hakea Prison to prevent other prisoners from barricading themselves into communal areas. The Coroner made six recommendations aimed at addressing the issues identified during the course of the inquest, including the provision of adequate counselling services and the deployment process for the SOG.
Catch Words: Incident Management Training : Deployment of SOG : Negotiator Training : Ligature Minimisation : Adequate Mental Health Support in a Prison Setting : Suicide.
Report: Bret Lindsay CAPPER