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WA Coroner finds culturally safe care in prison "may well have" saved young Indigenous man's life

Giovanni Torre -

A Western Australian coroner has accepted expert opinion that the life of Stanley Inman Jnr, a Noongar and Wirlomin man who died in Acacia Prison at nineteen years of age, could have been saved if there had been culturally safe care provided to him.

Mr Inman Jr was found unresponsive in a storeroom at Acacia, near Perth, on July 11 2020, the day after a psychologist and a risk assessment team reduced his level of supervision for the second time in two days. He passed away in hospital two days later.

A coronial inquest into Mr Inman's death was held from 9-10 May this year.

Coroner Michael Jenkin's findings drew attention to the "discouragingly low" [Paragraph 124] number of First Nations staff employed at Acacia Prison (20 out of a total of 325 staff), and he said "it is disappointing that the Aboriginal Visitors Scheme (AVS) ceased at Acacia in April 2022, when the AVS visitor resigned" [Paragraph 127] after Mr Inman's death.

Responding to an analysis of culturally safe care in WA Prisons from Professor Pat Dudgeon, Director of the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention, the coroner wrote:

"I strongly encourage both Acacia and Department of Justice to carefully review the recommendations outlined in Professor Dudgeon's report."

Coroner Jenkin concluded, in paragraph 139, that "It is also possible that had the culturally safe care referred to in Professor Dudgeon's report been available at Acacia, Mr Inman's life journey may well have been different".

"The overall quality of Mr Inman's supervision, treatment and care was of a lower standard than it should have been because his level of risk was not properly understood," he wrote in paragraph 133.

On Wednesday human rights advocates said the coroner's findings highlighted the continuing failure of WA prisons to provide First Nations people with adequate cultural safety.

George Newhouse, Principal Solicitor of the National Justice Project - the human rights law firm that represented Mr Inman's mother in the coronial inquest - said the report shows that the WA government "does not prioritise culturally safe care for First Nations people in WA prisons".

"It is deeply troubling that Acacia Prison does not draw upon the cultural expertise of First Nations people through more employment opportunities and well-resourced cultural support schemes like the Aboriginal Visitors Scheme," he said.

"First Nations prisoners, advocates and communities have told the Government tirelessly that culturally-appropriate healthcare delivered by Aboriginal Medical Services would help prevent the abhorrent rates of deaths in custody – its time they listen."

Megan Krakouer, Director at the National Suicide Prevention & Trauma Recovery Project, said the report shows that the largest prison in WA is not being serviced by an Aboriginal Visitors Scheme (AVS) scheme.

"Hundreds of Indigenous people in Acacia Prison are being denied psycho-social support because of this failure. Stanely Inman Jnr was failed by a system that was supposed to rehabilitate and protect him until he could come out be with his family. Instead, Stanley was shown disrespect and a lack of care by WA Corrective Services," she said.

A spokesperson for the WA Department of Justice told National Indigenous Times that the Coroner's report "highlights a number of improvements made by Acacia Prison following Mr Inman's passing, including improved assessment and management of prisoners who pose a risk to themselves".

"The Department of Justice continues to develop programs and initiatives to support Aboriginal people in its care including working with community and advocacy groups to form a holistic understanding of the needs of Aboriginal people," he said.

"Acacia Prison operates a range of support services for Aboriginal people including the Real Support Network, Derbal Yerrigan services and dedicated Aboriginal staff to guide and deliver culturally appropriate services."


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