Inquest into the Death of Ashley James BROPHO

Contributing factors

• Failure to conduct required PMDT review of Evan Martin's protection status
• Martin's documented history of premeditated vigilante violence against child sex offenders
• Martin's threat to stab prisoner SB in September 2022 and reported intent to harm child sex offenders
• Absence of CCTV in Unit 10 preventing observation of prisoner interactions and entry to cells
• Unit 10 short-staffing on 8 March 2023 reducing close staff interaction with prisoners
• Bropho's intellectual impairment and vulnerability making him unlikely to disclose assault
• Minor nature of injuries from 8 March attack reducing likelihood of detection

Coroner's recommendations

1. As a matter of urgency, ensure installation of closed-circuit cameras in unit wings, unit dayrooms, common areas and recreation yards within Units 6 and 7 at Hakea Prison
2. Reinforce compliance with Commissioner's Operating Policy and Procedure 10.2 through Commissioner's Broadcast and refresher training to all prison officers
3. Amend Clause 5.3.3 of COPP 10.2 to require Unit Manager to sign Occurrence Book confirming that general health and wellbeing visual check has been undertaken at lock-up
4. Amend COPP 4.10 to reflect the ability for ad-hoc review of a prisoner's protection status outside the 6-monthly mandatory review and to require PMDT to consider the risk posed by a prisoner to other prisoners within protection units
5. Consider whether COPP 4.10 should expressly require review of protection status when a prisoner is transferred between prisons
6. Create capacity in TOMS to place an alert on a prisoner indicating that the prisoner poses a risk to a specified cohort of prisoners
7. Prioritise creation of a group responsible for oversight of movements and placement of high-risk prisoners who have been involved in serious incidences of violence within the prison system resulting in serious harm or death