Inquest into the Death of Jayden Stafford BENNELL
Deceased
Jayden Stafford BENNELL
Demographics
20y, male
Date of death
2013-03-06
Finding date
2017-02-28
Cause of death
ligature compression of the neck (hanging)
AI-generated summary
Jayden Stafford Bennell, a 20-year-old Aboriginal man and sentenced prisoner at Casuarina Prison, died by ligature compression of the neck (hanging) in a cleaning storeroom on 6 March 2013. He had a complex psychiatric history including drug-induced psychosis, depression, and anxiety, for which he was frequently non-compliant with antipsychotic medications. Critical clinical failures included: (1) no psychiatrist review for seven months following transfer to Casuarina in November 2012, despite known ongoing psychotic symptoms and diagnostic uncertainty; (2) inadequate mental health resources resulting in suboptimal psychiatric care compared to his previous excellent care at Hakea Prison; (3) unrestricted access to a ligature minimisation-exempt communal storeroom; and (4) insufficient coordination when he failed to attend an afternoon program. The coroner found the mental health care at Casuarina 'inadequate,' describing the lack of psychiatric access as a 'lost opportunity' for risk assessment, though noting that more frequent psychiatric contact may not have altered outcomes given potential medication cessation and impulsive decision-making.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Contributing factors
- non-compliance with antipsychotic and mood stabilising medications
- ongoing psychotic symptoms with uncertain diagnosis
- depression and anxiety disorders
- impending lengthy sentence
- relationship difficulties with girlfriend
- minor drug debts and substance abuse in prison
- childhood trauma and exposure to domestic violence
- loss of contact with treating psychiatrist following prison transfer
- limited psychiatric services at Casuarina Prison
- unrestricted access to cleaning storeroom with multiple ligature points
- inadequate supervision and monitoring of mental health in custody
Coroner's recommendations
- The Department of Corrective Services should invest significantly more resources in ensuring that prisoners are given regular access to psychiatrists and place emphasis on providing a more holistic approach to mental health care when planning future changes to mental health services provided to prisoners.
- Efforts should be made to hire Aboriginal mental health workers to form part of the mental health team in prisons.
- Cleaning storerooms in Unit 5 to be locked outside designated morning hours (7.30 am to 10.30 am) with doors locked open during those hours for visibility; access at other times to be provided only under direct supervision.
- Storeroom light to be used as standard practice during the three-hour daily opening period.
- Submissions relating to broader death in custody investigation procedures and Royal Commission into Aboriginal Deaths in Custody recommendations to be referred to the State Coroner for consideration in the wider coronial practice review process.
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