Coronial
WAother

Inquest into the Death of Jomen BLANKET

Deceased

Jomen BLANKET

Demographics

30y, male

Date of death

2019-06-12

Finding date

2023-08-21

Cause of death

ligature compression of the neck (hanging)

AI-generated summary

Jomen Blanket, a 30-year-old Aboriginal and Torres Strait Islander man, died by suicide in prison on 12 June 2019 after eight months incarcerated for assault. He had a known suicide plan (hanging from his cell door using a bedsheet ligature) documented by staff for eight weeks before his death. On the morning of his death, staff correctly identified elevated suicide risk and arranged transfer to a safe cell, but an unanticipated delay due to shortage of available safe cells gave him opportunity to implement his plan. Critical failures included: inadequate communication of risk information to the psychiatrist (Dr B. received no details of his hallucinations, previous suicide attempts, or specific hanging plans), allowing him to close his cell door while alone despite known suicidal intent, and failure to have enough safe cells at the facility. The coroner found the lack of supervision during the cell door closure to be a grave error and contributing factor, given the known plan had been documented since 22 April 2019.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatrycorrectional healthpsychology

Error types

communicationsystemdelay

Clinical conditions

depressionanxietyearly-onset psychosisprodromal psychosissuicidal ideationnon-suicidal self-injuryhallucinations (auditory and visual)delusionstrauma

Contributing factors

  • inadequate number of safe cells at Acacia Prison (only 6 out of 1059 cells)
  • failure to prevent prisoner from closing cell door while alone despite known specific suicide plan
  • lack of supervision during unexpected delay in transfer to safe cell
  • failure to communicate critical risk information from social worker and PRAG to psychiatrist
  • incomplete mental health assessment by psychiatrist due to missing information about hallucinations and previous suicide attempts
  • prisoner allowed to remain in regular cell rather than ligature-minimised safe cell despite elevated risk identification

Coroner's recommendations

  1. Funding be provided as a matter of urgency for a project definition plan for creation of a therapeutic care unit at Acacia to treat mentally unwell prisoners at high risk of self-harm who do not meet criteria for involuntary admission
  2. Department's pilot Parole-in-reach Program involving AOD and FDV programs for short-term prisoners ineligible for IMPs be fully implemented and made available to general prison population
  3. Person from prison health service providing psychological and counselling support be on standby if prisoner may require such support after being informed of Prisoner Review Board decision regarding parole
  4. Serco ensure PRAG chairperson aware that prisoner on ARMS must be invited to attend case review unless not in prisoner's interests; Department ensure other prisons comply with ARMS Manual section 7.5
  5. Provision added to ARMS Manual section 7.5 entitling prisoner attending case review to have suitable support person accompany them
  6. Prison after-hours health service providers and PRAG chairperson have access to mobile telephone numbers of prison's mental health service providers for urgent contact regarding prisoner mental welfare
  7. If Department's Review of Death in Custody at Acacia accepts findings or recommendations from Serco's Post Incident Review, the Department Review should clearly identify that acceptance
Full text
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Source and disclaimer

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