Inquest into the Death of Damien George Garlett

Contributing factors

• Chronic underlying suicidal ideation not adequately monitored
• Failure to implement recommended mental health nursing review
• Inadequate establishment of therapeutic rapport with vulnerable young prisoner
• Removal from Disturbed and Vulnerable list despite unmet recommendations
• Over-reliance on subjective self-assessment of suicidal risk
• Lack of comprehensive psychiatric assessment despite history of drug-induced psychosis and self-harm
• Separation of Prison Counselling Service from Health Services disrupting continuity of care
• Lack of family visits contributing to emotional distress
• Prior alleged hanging attempt not properly documented or investigated
• Access to implements (shoelaces) suitable for impulsive hanging in cell with accessible light fitting
• Impulsive personality combined with inability to access therapeutic support

Coroner's recommendations

1. The Department of Justice encourage the use of Aboriginal help workers in Prison System, particularly Hakea which is the reception prison for all Prison admittees
2. Issue of shoes with Velcro fastenings as opposed to shoelaces be maintained
3. More comprehensive assessment of the use of flush light fittings and other hanging points in the cells in areas used by young remand prisoners
4. Prison Officers Training in Culture and Lifestyle of Aboriginals including PCS and MHS
5. Have a think about family access to prison
6. Have a think about money and accounts and the education of Prison Officers on discovery of a body
7. Implementation of Gatekeeper Programme suicide intervention training for all Prison Officers
8. Enhanced coordination between Health Services and Prison Counselling Services
9. Continued resourcing and funding for psychiatric and psychological input for monitoring prisoners
10. Improved central record keeping with controlled access to relevant information