Western Australia's Inspector of Custodial Services has released a major report on the state government's response to recommendations arising from coronial inquiries into deaths in custody, finding that authorities "often" prematurely closed coronial recommendations.
The directed review of the Department of Justice's performance in responding to the recommendations was commenced following a direction to the Inspector of Custodial Services by the Minister for Corrective Services, Bill Johnston, under Section 17(2)(b) of the Inspector of Custodial Services Act 2003 (WA).
Despite making "noticeable improvements" in governance and internal oversight practices, the report released today, 17 April, by Inspector of Custodial Services Eamon Ryan, found the Department of Justice was "often prematurely closing coronial recommendations without fully addressing the spirit and intent of the recommendation".
Between 2017 and 2021, the Coroner's Court made 35 formal recommendations to the Department of Justice following 13 inquests into the deaths of 17 prisoners in custody.
The report released Monday examined the Department's closure evidence for 10 of these recommendations and assessed how changes implemented may help prevent future deaths.
Mr Ryan found that, in several cases, the Department's focus was "more about closing recommendations than implementing effective change on the ground".
"While I feel the Department takes seriously its responsibility to prevent future deaths in custody, it was disheartening to find many recommendations were closed with little evidence of any meaningful change to practices," he said.
"We found this was the case across a range of issues, including additional mental health resources, reducing ligature points across prison infrastructure, and providing staff with sufficient training."
Many coronial recommendations related to improving the quality of mental health care provided to prisoners. In December 2022, nearly 12 per cent of adult prisoners and young people in detention were assessed as having a psychiatric condition or requiring further assessment f or a suspected psychiatric condition.
"My Office has long reported that mental health services for prisoners in crisis or with acute needs was inadequate and often inaccessible," Mr Ryan said.
"This report confirms that, despite several coronial recommendations, mental health services in prisons remain under-resourced. Custodial staff are not adequately trained in mental health care and clinical staff are under significant pressure. However, the Department has made improvements to their triage system and has improved information sharing across health staff."
More than one third of all deaths in prison custody between 2000 and 2021 in Western Australia were people identifying as Aboriginal.
Mr Ryan noted the recent anniversary of the Royal Commission into Aboriginal Deaths in Custody and the many outstanding recommendations of that report.
"Unnatural deaths in custody are an absolute tragedy that have far reaching impacts for everyone involved, but none more so than for the families of those who pass. It is imperative that every preventative measure that is reasonably possible be supported and implemented by government to help prevent future deaths in custody," he said.
"One unnatural death in custody is one too many, but one that could have been foreseen and prevented is entirely unacceptable. With this in mind, it was disappointing to find many vacancies in the Aboriginal Visitor Scheme and in Prison Support Officer positions. These support-based roles were created in response to the Royal Commission into Aboriginal Deaths in Custody to help prevent self-harm and suicide.
"The Department must ensure that AVS and PSO positions are filled across the prison estate if its role in preventing future deaths is to succeed."
Mr Ryan welcomed that the Department, in response to this review, "shared many of the concerns raised in the report and had recently changed their approach to responding to coroner's recommendations".
"The Department now takes a more pragmatic approach to coronial recommendations," he said.
The Department supported 11 of the 14 recommendations made in the report and noted they would perform a one-off audit of all closed recommendations, including those previously audited.
The list of recommendations and the WA Department of Justice's level of support is as follows:
Supported in Principle - Recommendation 1: Ensure a 'High/Significant' or 'Extreme' risk rating is attached to coroners' recommendations so that PAR audits 100 per cent of coroners' recommendations in the annual audit process
Supported in Principle - Recommendation 2: Track and disseminate 'suggestions' made by the Coroner
Supported – Current Practice/Project - Recommendation 3: Ensure PHS is adequately resourced for all prisons across Western Australia
Supported in Principle - Recommendation 4: Change policy to ensure that prisoners with a mental health history are seen by a mental health professional within 24 hours of reception
Supported in Principle - Recommendation 5: Include mental health assessments by a qualified mental health practitioner in applications to place prisoners on a confinement order
Not supported - Recommendation 6: Physically locate mental health staff in management units
Supported – Current Practice / Project - Recommendation 7: Reconsider the Coroner's recommendation to review light fittings in cells
Supported – Current Practice - Recommendation 8: Ensure a minimum standard of infrastructure and services is maintained at Broome Regional Prison until the new prison is built
Not Supported - Recommendation 9: Remove ligature points in the minimum-security ablutions block at Broome Regional Prison
Not Supported - Recommendation 10: Deliver anti-social personality disorder training to custodial staff
Supported – Current Practice / Project - Recommendation 11: Re-engage with the Mental Health Commission in an effort to secure contextualised and ongoing Gatekeeper training for custodial staff
Supported in Principle - Recommendation 12: Ensure all senior officers receive regular critical incident management training
Supported – Current Practice / Project - Recommendation 13: Ensure AVS positions are filled across the prison estate
Supported – Current Practice / Project - Recommendation 14: Ensure criminogenic programs that are delivered demonstrate efficacy
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A spokesperson for the WA Department of Justice said the department is "committed to identifying practical solutions to issues raised in recommendations by the State Coroner about deaths in custody".
"The Department endeavours to prioritise and implement recommendations that will improve the safety and wellbeing of people in its care. However, it recognises the significant challenges in realising some practice changes recommended by the Coroner given the complexities of the prison environment. The Department now undertakes a feasibility assessment and consults with relevant stakeholders as part of its review of Coronial recommendations."
The spokesperson said 10 recommendations examined in the Inspector's report were classified as 'closed' at the time, "noting that changes to policy, strategic direction and the current environment may warrant further actions".
Department Director General Dr Adam Tomison said the department takes deaths in custody "very seriously" and places "great emphasis on responding appropriately to recommendations made by the Coroner".
"We've established a Lessons Learned process which identifies immediate actions and opportunities to enhance the safety of people in custody and reduce the likelihood of unnatural deaths," Dr Tomison said.
Corrective Services Commissioner Mike Reynolds said a suicide prevention strategy and governance unit had been initiated to better manage at-risk and vulnerable prisoners.
"We're also working hard to bolster mental health care for prisoners, including the development of dedicated units in two prisons and regular training in this area for prison officers," Commissioner Reynolds said.
