Inquest into the Death of Wayne Thomas LARDER

Contributing factors

• Inadequate suicide risk assessment and management
• Mental health staff lacked access to Statement of Material Facts
• Mental health staff lacked access to Psychiatric Services Online Information System (PSOLIS)
• Reduction from high ARMS to low ARMS on 21 February despite documented risk factors
• Inadequate ARMS observations (one face-to-face observation in 18 hours)
• Placement in three-point ligature minimised cell with accessible ligature points
• Failure to communicate court concerns about suicidality to custody staff
• Inadequate safe cell capacity (only 6 safe cells for 900+ prisoners)
• Lack of formal PRAG Chair training
• Failure to search cell before prisoner placement
• Volatile emotional state and impulsivity following court appearances

Coroner's recommendations

1. Introduce face-to-face training for PRAG Chairs incorporating scenario-based training, roleplays and other appropriate delivery methods
2. Establish a Suicide Prevention Governance Unit to provide formal quality assurance, oversight, and auditing of PRAG decisions and promote consistency in ARMS application
3. Reinforce PRAG consideration of static and dynamic risk factors, particularly recent presentation, suicidal and self-harm ideation and behaviour
4. Require PRAG to carefully document decisions to reduce prisoners from High ARMS to Low ARMS with rationale and factors prompting the decision
5. Explore feasibility of providing all staff conducting ARMS assessments with access to Statement of Material Facts
6. Improve sharing of Psychiatric Services Online Information System (PSOLIS) information among staff conducting ARMS assessments
7. Give urgent consideration to providing prison mental health nurses with access to Standardised Risk Management Tool
8. Undertake immediate remedial work to ensure all cells housing newly admitted prisoners are fully ligature minimised
9. Take immediate steps to ensure all cells are three-point ligature minimised as quickly as possible, with view to full ligature minimisation over time
10. Conduct urgent review of all three-point and fully-ligature minimised cells to ensure fittings are truly 'ligature approved'
11. Increase number of safe cells at Hakea from six to 12 as a matter of utmost urgency
12. Explore feasibility of introducing regular refresher training for Gatekeeper program for all prison officers
13. Include training in effective management of prisoners with personality disorders and common mental health conditions
14. Conduct review to determine adequacy of resources and facilities at Hakea to manage prisoners with complex mental health issues
15. Consider feasibility of establishing a mental health unit at Hakea staffed by mental health practitioners and custodial staff