Inquest into the Death of Brian John KEALY

42y · Male·Ligature compression of the neck (hanging)

Brian Kealy, aged 42, died by suicide via hanging at Hakea Prison on 2 August 2024 while on remand. He had complex mental health needs including probable schizophrenia, anti-social personality disorder, and polysubstance use disorder. The coroner found the quality of mental health care provided was poor, attributable to systemic fragmentation between Psychological Health Services and Prison Mental Health teams operating in treatment silos without multidisciplinary meetings or effective information sharing. Dr F., a senior psychiatric registrar (not consultant psychiatrist) covering for an absent senior clinician, ceased olanzapine medication in May 2024, characterizing Brian's requests for reinstatement as drug-seeking behaviour despite his documented therapeutic response. Independent psychiatrist Dr B. opined olanzapine should have been continued. The coroner identified staff shortages, inadequate psychiatric oversight, failures in clinical governance, and poor information access as contributing factors. Five recommendations addressed systemic issues including multidisciplinary care models, information systems integration, and staffing adequacy.