Inquest into the Death of Alf Deon EADES

Contributing factors

• failure to respond appropriately to multiple cell call alarms
• failure to report serious safety concerns (child sex offender allegations)
• unprofessional conduct by prison officers answering cell calls
• failure to escalate safety concerns to senior management
• failure to investigate prisoner's request to be moved to crisis care
• failure to conduct proper risk assessment during cell breach
• failure to provide secure placement following safety disclosures
• inadequate supervision and oversight of cell call responses
• assault by multiple prisoners

Coroner's recommendations

1. Issue Commissioner's Bulletin reminding all custodial staff of importance of complying with cell call policies
2. Amend cell call policy to require custodial staff to identify themselves by surname when responding to cell calls
3. Reinforce protocols for reporting cell call system issues and conduct regular audits, with remedial action completed urgently
4. Install CCTV cameras in all remaining accommodation units at Hakea Prison not currently equipped, as matter of urgency
5. Amend policies to require custodial staff to speak separately to all cell occupants when a cell is breached for safety concerns
6. Provide training to all custodial staff on effective management of prisoners with personality disorders, mental health illnesses, and behavioural issues
7. Amend medication policies to ensure clinical staff inform senior unit officers when prisoners miss significant medication at scheduled parades, with urgent provision of missed medication