Inquest into the Death of Phillip John ALLEN
Deceased
Phillip John ALLEN
Demographics
47y, male
Date of death
2020-07-29
Finding date
2024-02-06
Cause of death
ligature compression of the neck (hanging)
AI-generated summary
A 47-year-old Aboriginal man died by suicide in custody at Roebourne Regional Prison while on SAMS mental health monitoring. He had paranoid ideation, delusions about 'black magic', and auditory hallucinations, which were reviewed by prison psychiatry and recommended for brain imaging and cultural counselling—neither completed before his death. Mental health care was adequate given resources and COVID-19 restrictions. However, critical supervision failures occurred: the night shift officer conducting the final cell count failed to account for all prisoners (not knowing Mr Allen's whereabouts in the cell) and made an inaccurate occurrence book entry. The supervising senior officer, despite being informed the count was incomplete, did not mandate a recount. Lack of culturally appropriate support, delayed recognition of delusions, and inadequate night shift cell checks were identified failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- probable psychotic disorder with delusions and auditory hallucinations
- chronic alcohol dependency with likely frontal lobe impairment
- inadequate night shift cell and body check by prison officer
- failure of supervising officer to ensure proper count after being informed count was not completed
- delayed recognition of delusional and psychotic symptoms by health services
- lack of culturally appropriate mental health support
- COVID-19 restrictions limiting access to cultural and family support
- absence of brain imaging and blood tests to clarify aetiology
- multiple ligature points in cell infrastructure
- inaccurate occurrence book entry misrepresenting completion of body count
Coroner's recommendations
- Implementation of two-officer requirement for night shift cell and body checks (one recording, one conducting visual count and welfare check) as per revised Local Order - S6
- Shortening of cell toilet doors and relocation of locks to top of door with sliding bolt mechanism for improved accessibility
- Installation of internal mesh screening to toilet cubicle windows with diagonal metal grilles—completed in 2021 for multi-bed cells
- Enclosure of all cell windows internally with ligature-minimised mesh as part of air-conditioning installation scheduled for mid-2024
- Introduction of Aboriginal and Torres Strait Islander Mental Health First Aid training for prisoners and staff (commenced October 2020, pilot refresher Gatekeeper training for prison officers)
- Engagement of external agency to run staff and peer support prisoner training in suicidal awareness and Aboriginal mental health
- Embedding of cultural support, Aboriginal peer workers, and traditional healers into multidisciplinary mental health teams rather than ad hoc sourcing
- Proactive outreach to community/family members and cultural consultants as per SAMS Manual recommendations when prisoners present with spiritual or cultural issues
- Completion of recommended brain imaging and blood tests for prisoners with suspected alcohol-related cognitive impairment and psychotic symptoms
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