Inquest into the Death of Owen Duker Nugget WEAZEL
Deceased
Owen Duker Nugget WEAZEL
Demographics
41y, male
Date of death
2023-08-10
Finding date
2025-09-16
Cause of death
ligature compression of the neck (hanging)
AI-generated summary
Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been remanded in custody on 27 May 2023 and was initially placed on ARMS (At-Risk Management System) with close monitoring. Following psychological reviews in June, he was removed from ARMS on 8 June 2023 despite his counsellor Rebecca Forster recommending he remain on low ARMS due to residual substance withdrawal effects and ongoing suicidal ideation. Clinical lessons include: timely access to regular psychological counselling is critical when a prisoner is off ARMS; the prison counsellor's clinical judgment should carry substantial weight in PRAG decisions; adequate resourcing of prison mental health services is essential—there were insufficient counsellors to provide regular follow-up; and rapid situational stressors (legal issues, relationship separation) can trigger acute risk escalation in chronically vulnerable individuals. The coroner found the care was reasonable within resource constraints, but highlighted significant system failures including understaffing of psychological services, inadequate infrastructure for confidential counselling, and absence of a Crisis Care Unit.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- chronic suicidal ideation with previous attempts
- substance use disorder (methamphetamine, alcohol, cocaine)
- history of childhood trauma
- depression and anxiety
- recent loss of primary support person (partner) due to domestic violence restraining order
- legal representation conflict letter from ALS received on day of death
- difficulty contacting family members due to limited phone credit
- removal from ARMS despite counsellor's recommendation to remain on low ARMS
- lack of ongoing psychological counselling after removal from ARMS
- situational stressors related to upcoming court appearance
- insufficient infrastructure and staffing for mental health services in prison
- isolation in cell with easy access to ligature point (wardrobe door)
Coroner's recommendations
- Treasury give priority to funding the Department of Justice to undertake infrastructure changes to create appropriately private and therapeutic dedicated interview spaces for counselling services to be provided to prisoners at Albany Regional Prison, available at all times the counselling service is operating
- Treasury prioritise funding the Department of Justice to create a permanent additional full-time PHS counsellor position at Albany Prison to ensure general counselling service is consistently provided to prisoners seeking additional support, along with assessments for at-risk prisoners on ARMS and vulnerable prisoners on SAMS
- WA Government prioritise funding Corrective Services to properly undertake extensive program of work required to fully ligature minimise cells throughout prison estates, including older prisons such as Albany Prison
- PRAG chairs to be reminded of need to document rationale for not placing prisoner on SAMS and information considered in decision-making process
- Suicide Prevention Governance Unit to review whether PRAG Chair should be a clinical position or whether greater clarity is needed about steps to take when there is no consensus among PRAG members
- Prison management at Albany to consider fully ligature minimised cells or more than three-point minimised cells within general population units for at-risk prisoners
- Aboriginal Visitors Scheme to be better resourced and promoted as part of Aboriginal Suicide Prevention Strategy development
Full text
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