Inquest into the Death of Sean Theo WINMAR (Mr STW)
Deceased
Sean Theo Winmar
Demographics
46y, male
Date of death
2022-08-11
Finding date
2026-01-23
Cause of death
Complications of ligature compression of the neck (hanging)
AI-generated summary
Sean Theo Winmar, a 46-year-old Aboriginal man, died by suicide on 11 August 2022 while on an interim supervision order after his release from prison. He had depression, substance use disorder, and chronic suicidal ideation. The coroner identified critical gaps in care: (1) lack of accessible psychological support—he was referred to a forensic psychology service but remained waitlisted; (2) no structured substance use counselling despite substance misuse being his primary risk factor; and (3) inadequate cultural considerations in his management. Mr Winmar relapsed into drug use and feared returning to prison before his court hearing. The coroner found that earlier psychological support, culturally safe care, and proactive substance abuse rehabilitation—rather than monitoring alone—might have prevented his death. Key lessons: forensic psychology services require adequate funding and staffing; mental health intervention should begin early in supervision orders; Aboriginal offenders need culturally responsive, trauma-informed care.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Drugs involved
Contributing factors
- Inadequate psychological support due to forensic psychology service waitlist
- Lack of structured substance use counselling despite primary risk factor
- Fear of returning to prison following drug use breach
- Stress from interim supervision order conditions and restrictions
- Limitations on cultural activities (unable to attend country, funerals, hunting)
- Mental health deterioration and depression
- Recent relapse into methamphetamine use
- Insufficient mental health follow-up despite history of suicidal ideation
- System-focused rather than rehabilitation-focused approach
Coroner's recommendations
- Department of Justice review staffing and resourcing of the Forensic Psychological Intervention Team (FPIT) to reduce waitlist length, or explore alternative ways to provide psychological support to supervised offenders on both interim and final supervision orders
- WA Police and Department of Justice staff involved in supervising persons on HRSO Act orders should receive regular training in culturally safe and trauma-informed interactions, above and beyond standard cultural awareness training
- Department of Justice amend policies for HRSO Act orders to ensure Community Corrections Officers are required to offer appropriate psychological and substance use support related to identified risk factors from outset of the order; if FPIT cannot provide this, appropriate alternatives should be sourced
- Department of Justice ensure there is an independent Aboriginal and/or Torres Strait Islander representative at HRSO Review Committee meetings
Full text
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