Inquest into the Death of Matthew Francis LEACH

Contributing factors

• alcohol dependence and chronic substance abuse
• untreated depression and mental health disorder (possibly bipolar affective disorder)
• history of suicide attempts and suicidal ideation
• sentencing to additional imprisonment
• loss of external family support (father and partner both had restraining orders against him)
• removal from ARMS monitoring despite ongoing vulnerability
• failure to flag sentencing date as a date of interest (DOI)
• lack of pro-active psychiatric assessment and risk review before sentencing
• overcrowding and resource constraints in prison mental health services
• absence of psychiatrist at Hakea Prison
• no formal follow-up monitoring on the day of sentencing

Coroner's recommendations

1. As a matter of urgency, the State Government should approve funding requests by the Minister for Corrective Services to recruit suitably qualified mental health staff and extend existing facilities to provide appropriate mental health care (including counselling) to prisoners at Hakea Prison, starting with funding to develop a project definition plan.
2. The Department of Health and the Department of Justice should consult to consider whether an alternative model of mental health care for prisoners, such as the Queensland Model, should be implemented in Western Australia, to reduce pressure on limited mental health resources at Hakea Prison and implement principles of the National Statement of Principles for Forensic Mental Health.
3. The Department should consider lateral approaches to reduce ligature points in cells, including possible collapsible doors or modified door designs, while balancing security considerations.
4. All prisoners receiving post-court welfare checks by custodial officers, with referrals to mental health services as required.