Inquest into the Death of Owen Duker Nugget WEAZEL

41y · Male·ligature compression of the neck (hanging)

Owen Weazel, a 41-year-old Wakka Wakka man with chronic mental health issues, substance use disorder and previous suicide attempts, was found hanging in his cell at Albany Regional Prison on 10 August 2023. He had been remanded in custody on 27 May 2023 and was initially placed on ARMS (At-Risk Management System) with close monitoring. Following psychological reviews in June, he was removed from ARMS on 8 June 2023 despite his counsellor Rebecca Forster recommending he remain on low ARMS due to residual substance withdrawal effects and ongoing suicidal ideation. Clinical lessons include: timely access to regular psychological counselling is critical when a prisoner is off ARMS; the prison counsellor's clinical judgment should carry substantial weight in PRAG decisions; adequate resourcing of prison mental health services is essential—there were insufficient counsellors to provide regular follow-up; and rapid situational stressors (legal issues, relationship separation) can trigger acute risk escalation in chronically vulnerable individuals. The coroner found the care was reasonable within resource constraints, but highlighted significant system failures including understaffing of psychological services, inadequate infrastructure for confidential counselling, and absence of a Crisis Care Unit.