Inquest into the Death of Jayden Stafford BENNELL

20y · Male·ligature compression of the neck (hanging)

Jayden Stafford Bennell, a 20-year-old Aboriginal man and sentenced prisoner at Casuarina Prison, died by ligature compression of the neck (hanging) in a cleaning storeroom on 6 March 2013. He had a complex psychiatric history including drug-induced psychosis, depression, and anxiety, for which he was frequently non-compliant with antipsychotic medications. Critical clinical failures included: (1) no psychiatrist review for seven months following transfer to Casuarina in November 2012, despite known ongoing psychotic symptoms and diagnostic uncertainty; (2) inadequate mental health resources resulting in suboptimal psychiatric care compared to his previous excellent care at Hakea Prison; (3) unrestricted access to a ligature minimisation-exempt communal storeroom; and (4) insufficient coordination when he failed to attend an afternoon program. The coroner found the mental health care at Casuarina 'inadequate,' describing the lack of psychiatric access as a 'lost opportunity' for risk assessment, though noting that more frequent psychiatric contact may not have altered outcomes given potential medication cessation and impulsive decision-making.