Inquest into the Death of Corey Desmond DEVREE

41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (stab wound) to the chest

Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons include: (1) Critical failures in mental health assessment—Corey's disclosure of hearing voices and anxiety (21 August 2024) and his urgent request for a nurse appointment (14 October 2024) were not appropriately actioned, despite evidence of emerging mental health concerns. (2) Catastrophic delays in treatment needs assessment—Corey's assessment was deferred for nine months, preventing parole eligibility despite judicial recommendations for psychological intervention. (3) Inadequate supervision—Corey was left alone and unobserved for one hour immediately before his death in a workshop with access to tethered knives. (4) Systemic prison health failures—a voicemail system allowing public audibility of health requests was replaced with a confidential 'pink slip' system post-death. While suicide is inherently difficult to predict, adequate direct supervision on the day of death would almost certainly have prevented access to ligature materials and implements of self-harm.