Inquest into the Death of Khamsani Victor JACKAMARRA (also known as Hajinoor)
Deceased
Khamsani Victor JACKAMARRA
Demographics
36y, male
Date of death
2015-12-16
Finding date
2019-05-09
Cause of death
Ligature compression of the neck (suicide by hanging)
AI-generated summary
A 36-year-old Aboriginal man with cluster B personality disorder, substance abuse, and chronic self-harm risk died by ligature suicide in prison 2 hours after admission. He pleaded guilty to arson charges and was remanded pending surety papers. While in court holding cells, he exhibited frustration by head-banging when told he must remain in custody. Critical information about his mental state, medication non-compliance, and self-harming behaviour was inadequately communicated between SERCO (court custody) and prison reception due to documentation failures. Although the coroner found placement on mental health monitoring would not have prevented his death given the acute destabilization and impulsivity inherent to his condition, she emphasised that proper psychiatric assessment at reception, ligature minimisation, and information sharing between community mental health and custody are essential. The case highlights systemic gaps in managing prisoners with mental health issues transitioning into custody.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- cluster B personality disorder with rapid mood destabilisation
- chronic poly-substance abuse (amphetamine, cannabis, alcohol)
- acute stress from remand in custody pending surety
- failure to communicate critical information from court custody (SERCO) to prison reception regarding self-harm risk, medication non-compliance, and prior behaviour
- inadequate psychiatric assessment at prison reception
- accessible ligature points in shower block
- lack of mental health staff available for reception assessment
- understaffed and under-resourced Broome Regional Prison
- impulsivity associated with mental health disorder exacerbated by heavy substance use
Coroner's recommendations
- Retain and ensure B(R)P has appropriate services which acknowledge it is a major transition facility with all the known risks that raises
- Information sharing between medical, Prison Counselling Service and mental health services in prison and appropriate sharing of information between custodial facilities and organisations in the community caring for those with mental health issues
- Effective CCTV and practical ligature minimisation; good coverage on adjacent points to toilet and shower facilities may avoid welfare issues
- Prison officer training that those with prior suicide attempts are at elevated risk in custody regardless of their demeanour
- The promotion of active involvement of prisoners in caring for one another
- Realisation on behalf of custodial services that welfare and security go hand in hand; destabilised prison populations due to successful suicides become security issues
Full text
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