Inquest into the Death of Sean Kevin Hayes

24y · Male·plastic bag asphyxiation

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.