Inquest into the Death of Sam Phillip Chisholm LYNCH
Deceased
Sam Phillip Chisholm LYNCH
Demographics
27y, male
Date of death
2024-03-05
Finding date
2025-06-12
Cause of death
effects of fire
AI-generated summary
Sam Lynch, aged 27, died from effects of fire while in remand at Hakea Prison on 5 March 2024. Following a dispute over undelivered canteen items, Sam set his mattress ablaze with a lighter. The response was catastrophic: staff shortages prevented first responders from accessing fire equipment (G-wing hose cupboard jammed), breathing apparatus was inadequate, R-Kit respirators had been unsafe-tagged, and mattresses lacked fire-retardant covers. It took 16 minutes for extraction. The coroner found supervision grossly inadequate and the death preventable had Hakea possessed fire suppression systems, implemented smoking bans, maintained equipment properly, and had adequate staffing. Systemic failures across multiple domains—maintenance, training, equipment availability, and incident response protocols—contributed directly to the outcome.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- staff shortages preventing canteen distribution triggering prisoner agitation
- failure to install automatic fire suppression system in cells
- lack of fire-retardant mattress covers
- R-Kit respirators tagged out as unsafe from 23 January 2024
- G-Wing fire cupboard door jammed due to moisture/swelling from adjacent food preparation area
- H-Wing fire hose nozzle missing critical lever due to loose bolt
- inadequate maintenance of fire equipment
- prisoner access to cigarette lighters
- insufficient training on first response to fire
- delayed release of BA officers from units after Code Red call
- lack of adequate fire drills and BA training frequency
- no automatic fire suppression system at facility
- lack of body-worn cameras preventing investigation of alleged verbal abuse
- inadequate supervision due to probationary officers with minimal experience
- failure to call Department of Fire and Emergency Services
- intake assessment failed to identify ongoing risk despite previous self-harm history
Coroner's recommendations
- Install fire suppression system at Hakea covering all cells and common areas, considering internal funding or Treasury allocation
- Expedite smoking ban at Hakea with enforcement of tobacco/matches/lighter restrictions; provide nicotine substitutes, support services, counselling and diversionary activities
- Develop interim management policy restricting lighter and match access for high-risk prisoners (arson convictions, prior fire incidents)
- Enhance fire response preparedness via: reviewing Emergency Management Plan; conducting refresher training on first response including R-Kits, extinguishers, blankets, hoses with realistic scenarios; quarterly BA exercises; monthly don/doff practices for all BA officers; training for Entry Control Officers; enhanced BA incentives; system to track BA officers' location in Master Control Room
- Expedite CCTV installation in all accommodation units and common areas at Hakea
- Expedite body-worn camera rollout for all custodial staff at Hakea
- Introduce training packages for Senior Officer and Principal Officer roles including de-escalation, leadership, tactical command
- Redouble recruitment and retention efforts for skilled custodial officers
- Ensure compliance with EMF-DIR-022 Operational debriefing; ensure first responders participate in hot and cold debriefs for critical incidents including deaths in custody; distribute lessons learned reports to relevant staff
- Provide automatic standdown leave for staff involved in critical incidents including deaths in custody; ensure stress checks and support mechanisms per EMF-DIR-022
- Continue quarterly external contractor checks of fire extinguishers and hoses; regularly clean ventilation ducts to remove fire hazard materials
- Amend policies to ensure restraints on prisoners declared deceased are removed as soon as reasonably practicable
Full text
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