The legal organisation supporting the family of Ricky-Lee Cound, a Noongar man who died in custody in Western Australia aged 22, says the coronial inquest into his death reinforces "the critical need for considerable system reform in WA prisons", which "must come into action as soon as possible to prevent further Aboriginal deaths in custody".
This week the National Justice Project said Mr Cound's death highlights "the lack of culturally safe therapeutic care in our prisons and youth detention systems", an "issue identified by the RCIADIC over 35 years ago and requires urgent attention".
The NJP noted that other other systemic issues were touched upon during the inquest into the including: barriers to information being passed between places of custody and recorded appropriately, inevitably leaving dangerous gaps in inmates care; dire need for awareness training for prison staff of FASD and its varying presentations and symptoms; delivery of culturally safe care and support for First Nations inmates with FASD; and prioritisation of concerns for self-harm for inmates.
The organisation said it would continue to work with the Cound family "for real change so that no family has to go through the trauma of losing their loved one in custody ever again".
A National Justice Project spokesperson told National Indigenous Times that last week's hearings had revealed a series of failures.
"We... heard evidence that Ricky-Lee Cound was diagnosed with Foetal Alcohol Spectrum Disorder (FASD) in Banksia Hill Detention Centre in 2016, (and) this critical information was not considered to inform his treatment or risk management plans whilst he was detained in adult custody. This is the first coronial inquest in WA involving a confirmed FASD diagnosis," they said.
"Despite a recent history of self-harm during Ricky's period of incarceration at Hakea Prison in 2022, he was not provided with any therapeutic care, treatment or support for his mental health and emotional wellbeing beyond risk assessments.
"On 25 March 2022, Ricky-Lee Cound was removed from the 'At Risk Management System' which is utilised to monitor prisoners that are at risk of self-harm. Just hours after being removed, Ricky-Lee Cound requested to moved into a safe cell (observation cell) so that he could be "under camera for the night" as he had concerns for his welfare. This request was not actioned and the family believe that this missed opportunity directly resulted in his tragic death."
The NJP spokesperson also noted that the inquest heard CCTV images taken from Hakea Prison showed a prison officer placing a document under Ricky-Lee Cound's cell door on the morning of 25 March 2022.
"The family believe that this document may have been a dynamic risk factor to his mental health, yet due to poor record keeping practices, there is no record of what this document was," they said.
"(And) cell calls to the prison's master control room from other inmates warning officers of Ricky's self-harm risk were not prioritised."
The Western Australia Department of Justice told National Indigenous Times that the Department "has closely followed these proceedings and awaits the Coroner's findings and recommendations".
