Inquest into the Death of Natasha Leanne Quartermaine

25y · Female·Ligature Compression of the Neck (Hanging)

Natasha Quartermaine, a 25-year-old female prisoner at Bandyup Women's Prison in Western Australia, died by suicide via ligature compression of the neck on 27 August 2001. She had a long history of mental illness, personality disorder, and poly-drug abuse. On the morning of her death, she expressed suicidal ideation to multiple staff members, but no one initiated the At Risk Management System (ARMS), a protocol designed to prevent self-harm. Critical information about her distress was not communicated to supervising prison officers, and there were medication dispensing errors with her anti-psychotic medications in the weeks preceding her death. The coroner found the quality of supervision, treatment and care to be poor, with a complete breakdown in communication and failure to follow Department of Justice procedures. The coroner made recommendations to improve medication administration processes, ARMS documentation protocols, and access to ARMS information at medical centres.