Inquest into the Death of Brett Ashley DUTURBURE

Contributing factors

• failure to obtain interstate prison records from Northern Territory
• inadequate risk assessment due to missing mental health history
• lack of access to adverse childhood events information
• failure to identify significant suicide risk factors
• insufficient assessment of suitability for work camp placement
• management decisions made despite staff concerns
• relationship breakdown and financial pressures
• placement in minimum-security facility with minimal overnight supervision
• denial of suicidal ideation during intake assessment based on incomplete information

Coroner's recommendations

1. When a prisoner is first received at a prison in Western Australia, the prisoner should be asked whether they have ever been incarcerated in another State or Territory prison. Where a prisoner discloses having been incarcerated in another State or Territory prison, the Department should obtain records relating to that interstate incarceration (including medical records) as soon as practicable to ensure appropriate management.
2. The Department should give very careful consideration to the suitability of prisoners being considered for transfer to a work camp, and where a prisoner's suitability is not overwhelmingly clear, adopt a conservative approach and refuse the transfer.
3. The Department should conduct an audit of all work camps to ensure that fire alarms in prisoner cells sound in staff quarters.
4. The Department should consider reverting to the previous arrangement where only prisoners with unsupervised status are placed at work camps.
5. The Department should ensure that senior officers at work camps are involved in all prisoner assessments at intake meetings and that their concerns are given due regard.