Coronial
WAother

Inquest into the Death of Sean Kevin Hayes

Deceased

Sean Kevin Hayes

Demographics

24y, male

Date of death

1997-08-21

Finding date

2000-02-11

Cause of death

plastic bag asphyxiation

AI-generated summary

Sean Kevin Hayes, a 24-year-old male remand prisoner, died from plastic bag asphyxiation in his cell at Canning Vale Remand Centre in Western Australia on 20-21 August 1997. He had a history of psychiatric illness, previous suicide attempts, and was on psychotropic medication (Stelazine, Zoloft). Hayes was assessed as "at risk" but released into the general population after an aborted self-harm attempt on 11 August. He experienced significant distress when his de facto wife failed to visit him as planned on 20 August. Despite having communicated suicidal intent to his cellmate Steven Berecz that evening, guards conducting five nightly cell checks between 20:25 and 06:35 hours failed to identify his deterioration. Prison Officer Rowley at the 06:35 unlock also failed to confirm Hayes was alive. The coroner found the death was suicide, identified systemic failures in cell-checking procedures and conflicting Standing and Local Orders, inadequate support for prisoners in double-up cells, and insufficient mental health resources. Key recommendations included resolving the Standing Order 1 versus Local Order 30 conflict, implementing written protocols for companion prisoners, ensuring all inmates know of peer support systems, and undertaking an independent review of prison health staffing levels.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatrycorrectional healthforensic medicine

Error types

systemcommunicationdelay

Drugs involved

stelazinesertralinenitrazepam

Clinical conditions

psychotic type personality disorderborderline psychotic thinkingdepressionsuicidal ideation

Contributing factors

  • history of psychiatric illness and previous suicide attempts
  • failed visit from de facto wife on planned date
  • suicidal ideation and intent communicated to cellmate
  • failure of prison officers to confirm prisoner alive during nightly cell checks
  • failure of unlock officer to confirm prisoner alive
  • conflicting Standing Order 1 and Local Order 30 regarding cell checks
  • prisoner placed in general population rather than observation cell despite at-risk status
  • inadequate support and briefing for companion prisoner in double-up cell
  • delay in notifying police of death

Coroner's recommendations

  1. Resolve in the strongest terms possible the apparent conflict between Standing Order 1 and Local Order 30 regarding cell checks in the very near future
  2. Prisoners asked to share a 'double-up' cell with an 'at risk' prisoner be given written advice as to what action to take in the event of the 'at risk' prisoner talking of suicide or self harm
  3. Procedures be implemented to ensure that all prisoners are aware of the Peer Support system and how to obtain assistance if desired
  4. Record the time and date at which medication is administered in writing
  5. Referrals from one health professional to another health professional be written and retained during the prisoner's term of sentence
  6. Undertake an independent review by a properly qualified person independent of and not beholden to either the Ministry of Justice or the Western Australian Government to determine whether there are sufficient medical practitioners and/or health professionals employed by or at the disposal of the Ministry of Justice to provide an efficient and timely health service to prisoners
Full text
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