Inquest into the Death of Bradley William Rapley

Contributing factors

• Suicide by suffocation using plastic bag
• History of depression and anxiety
• Past self-harm attempts in the community
• Escape from prison and re-sentencing, creating psychological stressor
• Emotional visit with girlfriend where suicidal ideation was expressed
• Perceived insensitive comments from prison officers regarding medication timing
• Lockdown regime at Casuarina Prison creating psychologically hostile environment
• Possession of plastic bag from police lockup property
• Fragile and vulnerable psychological state
• Impulsive decision-making in response to perceived hopelessness
• Evasiveness by deceased about suicidal ideation and self-harm history

Coroner's recommendations

1. Specific guidelines should be implemented regarding plastic bags in prison; police lockup plastic bags should be removed and items placed in prison perforated bags rather than retained in original plastic
2. Prison medical files should be made available to receiving officers within 24 hours of prisoner arrival
3. Lock-up alert 'P10' should automatically accompany a prisoner to inform receiving officers of past concerns, including self-harm history
4. Cell alarm system should alert receiving officers to the source of the call at time of alarm activation, rather than leaving officers uncertain whether alarm has been deactivated
5. Prison authorities should consider decision-making protocols regarding notification of next of kin when a prisoner emergency occurs, with simultaneous provision of accurate medical information
6. Police notification of serious incidents should occur in a timely manner to prevent rumour and prisoner consultation gaps
7. Prison officers should be trained in recognizing vulnerability and low self-esteem in prisoner behaviour, particularly in lockdown regimes, to avoid misinterpretation of agitation as personal hostility
8. Consideration should be given to options available on discovery of a person in a self-harm position, including careful resuscitation procedures with attention to infection control and responder psychological support