Inquest into the Death of Brian John KEALY

Contributing factors

• Fragmented mental health and psychological health services with poor communication between teams
• Lack of multidisciplinary team coordination and governance
• Different clinical opinions between prison medical and psychological health services regarding diagnosis and medication appropriateness
• Inadequate access to forensic psychiatric assessment and court-ordered clinical recommendations
• Medication cessation (olanzapine) by senior medical officer despite prisoner's deterioration
• Insufficient staffing in mental health services leading to inability to provide timely counselling
• Limited therapeutic spaces and wait-lists for mental health appointments
• Antisocial personality disorder with drug-seeking behaviour, possibly masking genuine psychiatric illness
• Unclear clinical diagnosis (psychosis vs drug-induced vs personality disorder)
• Prisoner's repeated suicide threats viewed as manipulative rather than genuine psychiatric distress

Coroner's recommendations

1. Department of Justice should ensure that Psychological Health Services (PHS) and prison mental health clinicians have reciprocal access to prisoner information stored in the EcHO system and PHS module of TOMS respectively
2. Department of Justice should review delivery of mental health and psychological health services at Hakea in light of recommendations from independent psychiatrist Dr B., including forming a project group with Department of Health to determine feasibility of DoH assuming responsibility for all prisoner health care (primary, psychiatric, psychological), and assessing appropriateness of adopting a multidisciplinary model led by a psychiatrist
3. Department of Justice should ensure all available medical, psychiatric and other reports and information relevant to a prisoner's care and treatment are freely available to treating mental health and psychological clinicians, and identify and remove any legislative, policy or other barriers preventing such access
4. Department of Justice should ensure provisions of EMF-DIR-022 Operational debriefing are complied with, particularly ensuring personnel involved in critical incidents participate in immediate and formal debriefs and that lessons learned reports are disseminated to relevant staff
5. Department of Justice should conduct review of number of mental health and psychological health clinicians at Hakea to determine adequacy of staffing, and redouble recruitment efforts for vacant positions while reviewing salary and benefits to attract qualified clinicians