Warning: this article contains reference to suicide, self harm and the name of a person who has died.

Inadequate supervision and a shortage of safe cells at Acacia prison were factors in the death in custody of a 30-year-old Indigenous man in custody, a WA Coroner has found.

In his findings on the death of Mr Blanket on 12 June 2019, Coroner Philip Urquhart said that while it "appropriate" to allow Mr Blanket to enter his cell on the morning of 12 June 2029, Acacia staff should not have permitted him to close his cell door.

"It meant Mr Blanket was not adequately supervised, and he had the opportunity and the means to implement his known suicide plan at a time when he was at an elevated risk of self-harm," the inquest findings stated.

The Coroner was also critical of the "inadequate number of safe cells at Acacia which meant there was a delay in relocating Mr Blanket to such a cell on the morning he died".

"It was grossly inadequate that there were only six safe cells out of 1059 cells at Acacia," he said.

Mr Blanket had commenced a 12-month term of imprisonment on 23 October 2018, and it was the first time Mr Blanket had been imprisoned. On 6 November that year he was transferred to Acacia.

The Coroner found that throughout his imprisonment, Mr Blanket "struggled with his mental health and cultural beliefs".

He found that: "regrettably, the beginning of Mr Blanket's supervision, treatment and care was anything but 'culturally appropriate'."

Karen Blanket, Mr Blanket's mother, said she hoped the coronial findings push the WA government and Serco to take urgent action.

"I hope Serco and the Department of Corrective Services are listening to the Coroner, and that they will make urgent changes," she said in a statement issued via the National Justice Project.

"I am still heartbroken about the death of my son. I live with the loss and the grief every second of the day. I don't want any mother to have to go through what I have had to bear.

"I drove out to the prison three times when Jomen threatened to hurt himself. I told the guards about my concerns but they did not pass the information on to the supervisor. I tried to tell the prison about my son's suicide risk but no one took me seriously and no one passed on my plea for help to those who could have intervened and saved his life."

Mr Urquhart found that Mr Blanket self-harmed and expressed suicidal ideation on a number of occasions which had him regularly placed on the Department of Justice's primary suicide prevention strategy and under the management of Acacia's Prisoner Risk Assessment Group, and was often placed in a ligature-free safe cell so he could be closely monitored when he was considered to be at high risk.

On 22 April 2019, Mr Blanket was advised that he had been denied eligibility for parole which, the Coroner found, had a significant impact on his mental wellbeing. Later that day, he assaulted two other prisoners and attempted to take his own life, and alerted prison officers to the suicide attempt.

The Coroner noted that on 10 May 2029 Mr Blanket met briefly with the prison psychiatrist, who formed a view that he had "an evident psychotic illness in its early stages that had been preceded by affective depressive symptoms". At a second appointment with the psychiatrist on 30 May 2029, Mr Blanket declined to take any antipsychotic medications and had also stopped taking the antidepressant medication that had previously been prescribed by the prison doctor.

On the morning of 12 June 2019, a prison officer noticed Mr Blanket appearing distressed and raised her concerns with the Prisoner Risk Assessment Group chairperson, who directed that Mr Blanket be relocated to a ligature-free safe cell due to the heightened risk of self-harm. The Coroner found that while such a relocation usually took 10 to 15 minutes, on this occasion there was a delay during which Mr Blanket moved from the common area of the unit he was housed in to his one-person cell, where he closed the door and locked it from the inside.

At about 10.10 am, when the prison officer who had earlier noticed Mr Blanket's distressed state checked on him in his cell, unlocked the door and found Mr Blanket unresponsive against the inside of the door, and despite repeated attempts to resuscitate him, Mr Blanket could not be revived.

The Coroner determined that the manner of death was suicide, and also formed the view that Mr Blanket had used the same method he had described to prison officers in April 2019 and to a prison social worker on 14 May 2019.

While "generally satisfied with the treatment and care provided to Mr Blanket by the mental health service providers at Acacia", Mr Urquhart said that on the morning of 12 June 2019, Acacia staff should not have permitted him to close his cell door.

"It meant Mr Blanket was not adequately supervised, and he had the opportunity and the means to implement his known suicide plan at a time when he was at an elevated risk of self-harm," the Coroner found.

He was also critical of the inadequate number of safe cells at Acacia which caused the delay in relocating Mr Blanket to such a cell on the morning he died.

Mr Urquhart found that both these issues were contributory factors in Mr Blanket's death.

WA Greens MP Dr Brad Pettitt said there is "clearly an issue with safety at the privately-run Acacia Prison that contributed to the tragic death in custody of Mr Blanket".

"The lack of safe cells, along with other recommendations made by the coroner, must be urgently addressed by the Cook Government to improve prisoner safety and ensure that we never again find ourselves in this situation," he said.

The Coroner made a series of recommendations in response to the death of Mr Blanket:

Recommendation No. 1

In order to provide appropriate care and treatment for prisoners in Acacia, funding be provided as a matter of urgency for a project definition plan regarding the creation of a therapeutic care unit to treat mentally unwell prisoners (including prisoners who are deemed to be at a high risk of self-harm) who do not meet the criteria for an involuntary admission to an authorised hospital under the Mental Health Act 2014 (WA).

Recommendation No. 2

To address the previous inequality for access to treatment programs between prisoners who have been assessed for an IMP and those who have not, the Department's pilot Parole-in-reach Program (PiP) involving AOD and FDV criminogenic programs for short-term prisoners who are ineligible for IMPs be fully implemented and made available to the general prison population.

Recommendation No. 3

To enhance the care of vulnerable prisoners, a person from the prison's health service that provides psychological and counselling support be on standby should it be suspected that a prisoner may require such support after being informed of a decision from the Prisoner Review Board regarding the prisoner's parole eligibility. Preferably, this person should be one who is known to the prisoner.

Recommendation No. 4

So that there is compliance with section 7.5 of the ARMS Manual, Serco is to ensure that the chairperson of PRAG at Acacia is aware that a prisoner on ARMS must be invited to attend their case review, unless it is not in the prisoner's interests to do so.

The Department is to also take appropriate measures to ensure that case reviews at PRAG meetings in other prisons are complying with this part of section 7.5 of the ARMS Manual relating to the attendance of prisoners at their case reviews.

Recommendation No. 5

To overcome reluctance from a prisoner to attend their PRAG case review, a provision is added to section 7.5 of the ARMS Manual entitling a prisoner who is attending their case review to have a suitable support person accompany them.

Recommendation No. 6

To assist with the timely care and treatment of mentally unwell prisoners, a prison's after-hours health service providers and chairperson of PRAG have access to the mobile telephone numbers of the prison's mental health service providers if urgent and immediate contact is required regarding the mental welfare of a prisoner.

Recommendation No. 7

If the Department's Review of a Death in Custody at Acacia accepts any of the findings and/or recommendations made in Serco's Post Incident Review of the death, then the Department's Review should clearly identify that acceptance.