Inquest into the Death of Corey Desmond DEVREE

Contributing factors

• Delay in conducting timely mental health assessment (9 months overdue treatment needs assessment)
• Failure to escalate mental health concerns—hearing voices disclosed 21 August 2024 not referred to ARMS
• Inadequate response to urgent health request on day of death (voicemail 'ASAP' appointment request not followed up)
• Inadequate direct supervision in Paint Shop—left alone and unobserved for extended periods, particularly 1.5 hours before death
• Access to unsecured knives with inadequate tethering systems
• Systemic backlog in treatment assessments (1,143 prisoners across Western Australia waiting assessment)
• Insufficient staffing—only two qualified assessors at Bunbury Regional Prison
• Flawed health appointment request system (public telephone voicemail system)
• Failure to obtain Corey's prior medical history from Fiona Stanley Hospital despite disclosure of previous self-harm

Coroner's recommendations

1. The Department of Justice should, without delay, take all necessary steps to reduce the number of outstanding treatment assessments (1,143 statewide; 100 at Bunbury Regional Prison). Measures should include: (a) Streamlining the assessment process; (b) Placing greater reliance on external reports from psychiatrists and psychologists where available to inform treatment assessments; (c) Engaging additional psychologists on full-time, part-time, or contract basis.
2. The Department should undertake an urgent review of COPP 8.1 - Prison Based Constructive Activities to determine if a definition of direct/indirect supervision is required and, if so, clarify issues relating to safety and security parameters.
3. The Department should conduct an urgent review to determine appropriate supervision levels for prisoners in Industries area (Paint Shop, Metal Shop, Cabinet Shop etc.) at Bunbury Regional Prison, including: (a) Determining minimum supervision levels and acceptable Vocational Support Officer to prisoner ratios; (b) Feasibility of installing Close Circuit TV cameras monitored by Multi-Function office staff; (c) Policy for closing workshops when identified supervision cannot be provided.
4. The Department should institute a mechanism for regularly checking all Automated External Defibrillators (AED) at Bunbury Regional Prison to ensure each AED has a spare set of defibrillator pads (daily checks with occurrence book records now in place but recommendation maintained to entrench practice).