Inquest into the Death of Ricky-Lee COUND

Contributing factors

• FASD diagnosis not accessible or managed by custody or health staff
• removal from ARMS on 25 March 2022 without placement on SAMS despite meeting SAMS criteria
• failure to place on ARMS after cell call at 4:11 pm expressing self-harm risk
• incorrect assessment of genuine self-harm risk as not credible
• insufficient inquiries made regarding cell call request for safe cell placement
• inadequate FASD management plan and staff training
• lack of awareness of FASD as significant suicide risk factor
• static risk factors present: history of self-harm, substance abuse, FASD, impulsivity
• COVID-19 restrictions and prison overcrowding
• staff shortages and under-resourcing at Hakea Prison
• cell remained in damaged state with broken glass and accessible ligature point

Coroner's recommendations

1. Introduce mandatory training regarding the management and care of prisoners with FASD to new and current prison officers
2. Review operating policies and procedures to provide specific guidance on management and care of prisoners with FASD and other intellectual disabilities, including support strategies
3. Ensure Department applies relevant provisions of Sentencing Act 1995 (WA) to use court-ordered psychiatric or psychological reports prepared for sentencing to inform prisoner management, with formalised information sharing practices
4. Ensure custodial staff directly responsible for care of prisoners with diagnosed mental health conditions or intellectual disabilities affecting behaviour are informed of these disorders without requiring access to TOMS
5. Continue necessary and practical steps toward investment in body-worn cameras for prison officers at Hakea
6. Take immediate steps to ensure all cells at Hakea are three-point ligature minimised as quickly as possible, with view to full ligature minimisation; conduct urgent review of light fittings in ligature-minimised cells to ensure they are 'ligature approved'
7. As matter of utmost urgency, prioritise funding for works to improve infrastructure for health care (including mental health care) provision at Hakea
8. Introduce operational policy requiring placement in safe cell of prisoner who requests it due to concerns of self-harm; if placement does not occur, there must be sound basis after MHAOD consultation with reasons recorded