Inquest into the death of Duke Allan Wayne Schafer

Contributing factors

• Lack of CCTV monitoring in laundry area
• Limited staff visibility of laundry due to unit layout and obstructed windows
• Inadequate staffing in unit during muster periods with only one officer supervising
• Unsupervised laundry access for prisoners
• Perpetrator's premeditation and deliberate selection of time and location
• Failure to implement court-recommended specialist psychological treatment for perpetrator
• Inadequate systems to track and ensure compliance with court-ordered treatment recommendations
• Perpetrator's non-engagement with offered PMHS and CSCP programs despite multiple offers
• Delayed identification of risks posed by increased prisoner numbers and changed laundry access policies

Coroner's recommendations

1. The Assistant Commissioner, Specialist Operations should ensure that effective systems exist across the state to monitor compliance with court recommended programs and treatment for prisoners
2. Deputy Commissioners, Custodial Operations, and Community Corrections and Specialist Operations, should remind all staff that all relevant information regarding implementation of court recommendations, attempts to do so, or the rationale for determinations not to provide recommended treatments, should be recorded in IOMS
3. The General Manager, WFDCC, ensure all windows which provide visibility from WFDCC officer's stations into prisoner accommodation areas should be kept clear of all paper or any other item which may obstruct the view of officers working in those areas
4. The General Manager, WFDCC, reinforce the expectation that during musters in Secure 2 where only one Custodial Correctional Officer is left to supervise a unit, CCOs prioritise observations of prisoners in the units over the completion of routine administration tasks
5. The Assistant Commissioner, Central and Northern Region Command give consideration to whether supervision capacity of prisoners residing in accommodation areas at WFDCC can be improved, such as by increasing the number of CCOs rostered to work in those units or by modifying daily routines and task allocation
6. Implementation of End-to-End case management system with Engagement Plans to capture court-based recommendations
7. Return laundries to locked status with prisoner access only under direct correctional officer supervision
8. Conduct statewide review of laundries and kitchenettes to determine additional risk mitigation measures
9. Ensure all Death in Custody Operational Review Reports are referred to Operational Oversight Committee for tracking of recommendations