Inquest into the 5 Deaths in Casuarina Prison who are Mervyn Kenneth Douglas BELL and Bevan Stanley CAMERON and Brian Robert HONEYWOOD and JS (Name Subject to Suppression Order) and Aubrey Anthony Shannon WALLAM

Contributing factors

• Inadequate Prison Counselling Service staffing
• Inadequate mental health staffing
• Insufficient ligature-minimisation of cells housing at-risk prisoners
• Lack of reciprocal information sharing between PCS and Prison Health Service
• Over-reliance on prisoner denials of self-harm risk
• Failure to place prisoners at known chronic suicide risk on monitoring systems
• Inadequate risk assessment processes particularly for denial of self-harm
• Insufficient consideration of adverse childhood events in risk assessment
• Incomplete assessment of personality disorders and their management implications
• Lack of mental health triage on prison admission
• Insufficient supervision and monitoring frequency pre-2015
• Inadequate response to known ligature points
• Lack of communication protocols for prisoner telephone account changes
• Limited therapeutic intervention capacity for personality disorder management

Coroner's recommendations

1. Take urgent steps to recruit additional PCS and mental health staff for Casuarina Prison and review appropriate staffing levels across the State prison system
2. Increase the number of three-point and fully ligature-minimised cells at Casuarina Prison without delay, with priority given to units housing vulnerable prisoners; review whether light fitting covers currently used are fit for purpose
3. Take all necessary steps to ensure PCS and Prison Health Service staff have reciprocal access to prisoner information in EcHO and TOMS systems respectively to improve risk assessment
4. Introduce a triage system where prisoners with known history of self-harm or suicide attempts are reviewed by a mental health professional within 24 hours of reception, using video-conferencing for regional prisons
5. Consult with trauma-informed custodial care (TICC) experts to determine process for incorporating TICC principles into prisoner management at Casuarina Prison
6. Consult with mental health experts to provide training to all staff on features of personality disorders and mental disorders and strategies for effective management
7. Enhance the Gatekeeper training program to focus on suicide risk assessment in custodial settings with additional guidance for reception officers; implement regular refresher training
8. Amend Policy Directive 36 – Communication to require custodial staff to advise prisoners when changes are made to their Prison Telephone System account