Inquest into the Death of Bret Lindsay CAPPER

Contributing factors

• inadequate placement on SAMS after removal from ARMS despite meeting eligibility criteria
• insufficient Prison Counselling Service staffing preventing ongoing therapeutic interventions
• failure to provide long-term counselling for personality disorder despite identified need
• lack of reciprocal access between PCS and mental health computer systems
• false assumption by mental health team that deceased was receiving PCS support
• PCS staff non-attendance at mental health team meetings
• difficulty coping with custody and anticipation of lengthy prison sentence
• social isolation and limited protective factors
• lack of ligature minimisation in communal areas
• misunderstanding by staff about SAMS eligibility criteria

Coroner's recommendations

1. Review SOG deployment procedure and consider reverting to previous system allowing direct contact between prison officers in charge and SOG
2. Take urgent steps to recruit the nine approved additional PCS staff and consider appropriate staffing levels for prisons across Western Australia
3. Ensure PCS and Prison Health Service staff have reciprocal access to prisoner information in EcHO and Total Offender Management Solutions systems without delay
4. Expand information sessions about SOG role (currently delivered to prison health staff) to custodial officers
5. Provide critical incident management training to senior custodial officers (senior officers and above)
6. Consult with mental health experts to provide training to custodial staff on personality disorders and mental health conditions, with strategies to better manage affected prisoners