Inquest into the Death of Stanley John INMAN

Contributing factors

• failure of PRAG to access prisoner phone call recordings showing suicidal ideation
• inadequate mental health assessment at admission despite prior self-harm history
• insufficient appreciation of background risk level related to brother's death and family stressors
• lack of culturally safe care for Aboriginal prisoner
• insufficient involvement of Indigenous health workers in assessment and care
• unmonitored access to storeroom with potential ligature materials
• discrepancy between statements to staff versus family regarding mental state
• relationship breakdown with partner not disclosed to or known by prison staff
• ARMS observation level reduced without full information regarding stressors and ongoing distress

Coroner's recommendations

1. Every effort should be made to ensure that scrutiny of prisoner phone calls and mail for those on ARMS is as fulsome as humanly possible, to enable PRAG to make decisions about at-risk prisoners with greater understanding of their mental state
2. PRAG should routinely access and review phone call and mail content for prisoners being assessed for reduced ARMS observation levels, as now required by ARMS Manual section 4.3.3.1.5
3. Develop and implement an overarching cultural support policy for Aboriginal and Torres Strait Islander prisoners to ensure culturally safe care
4. Increase recruitment and retention of Aboriginal and Torres Strait Islander health workers, peer support staff, and Aboriginal Visitors Scheme (AVS) officers at all prisons
5. Implement standardised mental health assessments (e.g. MADRAS score) for all prisoners admitted to custody, particularly those with identified risk factors
6. Ensure involvement of Indigenous health workers in initial mental health assessments of Aboriginal prisoners
7. Implement processes to contact prisoner families for third-party information when assessing risk of self-harm, with prisoner consent where feasible
8. Maintain strict control of access to unit storerooms and other areas where ligature materials are accessible
9. Continue ensuring all response officers have immediate access to Hoffman knives
10. Enhance PRAG operational oversight through senior management attendance to incorporate operational placement and security risk assessment alongside clinical factors
11. Support the work of the newly established Suicide Prevention Governance Unit to provide quality assurance and oversight of PRAG decisions
12. Consult and implement recommendations from Professor Pat Dudgeon's report on culturally safe prison care for Aboriginal people