Inquest into the death of Kingsley Dean Garlett

Contributing factors

• access to illicit drugs and non-prescribed medications while in custody
• inadequate supervision of drug access in prison
• emotional relationship conflict with partner preceding death
• emotionally unstable personality disorder with impulsive features
• substance use (methylamphetamine, cannabis, benzodiazepines) impairing decision-making
• non-ligature minimised cell with accessible anchor point (bunk bed metal slats)
• delay in accessing methadone program (5-month wait after assessment)
• lack of real-time monitoring of prisoner phone calls

Coroner's recommendations

1. As a matter of utmost urgency, take immediate steps to ensure all cells at Casuarina are three-point ligature minimised as quickly as possible, with a view to ensuring all cells are fully ligature minimised over time. Finalise review of bunk beds and ensure all bunk beds are fit for purpose and can be described as 'ligature approved'.
2. Implement a replacement strategy for the expired Western Australian Prisons Drug Strategy 2018-2021 to provide strategic guidance to efforts to reduce the flow of illicit substances into prisons and to provide harm and demand reduction support to prisoners.
3. Government should reconsider the Department of Justice's submission for funding for additional Aboriginal support workers, counsellors and mental health professionals noting the critical need for such positions across the Western Australian custodial estate.
4. Consider expanding methadone and buprenorphine programs so that the wait time for prisoners to enter these programs is reduced.