Inquest into the Death of Annabel NICOL

Contributing factors

• chronic alcoholism and alcohol dependence
• severe depression
• profound feelings of shame and guilt about imprisonment and loss of reputation
• family history of suicide (brother died by hanging)
• lack of therapeutic environment in Crisis Care Unit
• prolonged remand in custody (almost 3 months)
• repeated remand adjournments causing loss of hope
• limited access to smoking and fresh air in CCU causing distress
• isolation and lack of social support within prison
• difficulty engaging with restrictive prison mental health regime
• inadequate dedicated forensic mental health facility for women
• CCU and management unit design preventing access to protective factors

Coroner's recommendations

1. Government should commit funding to the establishment of a subacute mental health unit in Bandyup Women's Prison, properly staffed with a multidisciplinary mental health team, as a matter of priority.
2. Government should commit funding to establish a 'female only' secure forensic mental health unit as a matter of priority.
3. The Attorney General should consider amending the Sentencing Act 1995 (WA) to permit the release of court ordered medical reports to the medical and nursing staff treating remand and sentenced prisoners to improve the level of care provided.
4. Prisoners in the Crisis Care Unit should be provided opportunities to smoke under staff supervision (implemented Phase 1: March 2019).
5. Temporary smoking facilities should be constructed for CCU prisoners (implemented Phase 2: March 2019).
6. Permanent therapeutic structures should be constructed at the rear of the CCU yard (Phase 3: construction commenced April 2019).
7. Enhanced therapeutic activities and stimulation should be provided to CCU prisoners (games, colouring, painting, musical instruments, yoga, Pilates).
8. Access to the CCU garden area should be provided to prisoners under supervision for fresh air and therapeutic benefit.