This report contains the name and image of a person who has died.

Three years after the death in custody of 22-year-old Noongar man Ricky Lee Cound, inquest findings have brought no closure for his family and loved ones who are still seeking justice.

The findings were released Wednesday by the Coroner's Court of WA.

Mr Cound's died in custody in March 2022, several weeks after he had been transferred to Hakea Prison from Acacia due to his involvement in a riot and placed on the risk management system (ARMS) due to self-harming.

Mr Cound was taken off ARMS and within three hours he asked to be placed in a CCTV-monitored cell so he did not self-harm, but this request was ignored. He look his own life hours later.

"The prison officer who answered Mr Cound's cell call arranged for a senior prison officer to speak to Mr Cound," Coroner Philip Urquhart's findings stated.

"After a short conversation with Mr Cound, the senior prison officer arranged for him to be given a radio and when that was not available, Mr Cound was provided a breakfast pack.

"He was not placed in a cell with CCTV monitors, nor was he placed on ARMS. Had he been in a safe cell, the risk of Mr Cound being able to end his life would have been significantly lower than the level of risk that existed within his cell in B Wing."

Ricky's mother, Laura Cound, told National Indigenous Times after the findings were released that she had been told they'd return to court to hear the findings, but instead found out about them via online news, which she found "appalling".

"We don't want this go away and for people to forget what really happened to Ricky. Ricky did cry out for help for days – the proof is in the transcript. I acted for him, as his mother, and no one listened," she said.

"My son didn't have to die because of that (inmates being in lockdown due to a COVID outbreak). He pleaded, he pleaded and begged for crisis care.

"He asked (for help), he said my mum's my rock, I don't want to leave her."

Giovanna McShane, whose daughter Bethany was Mr Cound's partner, told National Indigenous Times the Coroner had been "very fair".

"Ricky knew his FASD, he knew his triggers, so he wasn't scared to ask for help," Ms McShane said.

"The thing that upsets me most, and I know it upsets Laura and everyone, is the fact that, like the Coroner said, these actions (by the Department of Justice) - that is what failed Ricky.

"I don't think anyone really understands the impact that Ricky had on his family. Ricky was the go-to person, the protector."

"He was in charge," Ms Cound said. "He made sure things got done right. He got lost and ended up back in the system."

"Their actions are what failed my son, and our lives have been turned upside-down – we have a missing part.

"My son didn't have to die. They're saying there are going to be changes, but how many deaths have there been after Ricky? Wayne Ugle was a good guy, a rock for his family, and he only wanted his heart tablets."

Ms Cound revealed that Stuart Hume, the 29-year-old Noongar man who recently died in Casuarina, was her nephew.

"He was only young. He'd lost his father, and he wanted to go and sit with his family, his immediate family, (at his father's funeral) but they didn't allow that. Now we bury father and son together," she said.

"What is really going on in the prisons? That's what we need to know. What's really going on, because these deaths keep coming. You know, there's about six more deaths after that. There was that boy who got a lighter into his cell – how did he get it in there? How did he burn?"

On the day Ricky died in custody, half an hour after he sought monitoring he and two other inmates in the same unit broke their cell doors' viewing windows and threw broken glass and parts of fans from their cells into the corridor.

The Coroner found that despite the broken glass in his cell, it was "not checked or cleaned by prison staff", and that it was more than two hours before officers checked on Mr Cound again.

Within minutes of that check, a fellow inmate made a cell call warning them Mr Cound was "cutting up" and "blood's everywhere".

Instead of attending to him, the Coroner found, officers dealt with a water spill instead, stating it was "a potential hazard".

Other prisoners were making calls for Mr Cound to be checked on because he had not been heard from for some time.

That evening, at 7.26pm, Ricky was found unresponsive. Guards and prison nursing staff, then ambulance officers, attempted to resuscitate him but he never regain consciousness and later died at Fiona Stanley Hospital in Perth's southern suburbs.

The Coroner found "there were several missed opportunities identified that had they been taken, were likely to have reduced the time it took for the check on Mr Cound to take place".

Ms McShane told National Indigenous Times that on the last day of the inquest, "the lady from the Department of Justice turned around and looked at us, crying and said, 'on behalf of Department of Justice, we just want to say how sorry we are for what happened to Ricky'".

"They knew what they were doing. I mean, how do you go and check on somebody who is asking for a safe cell, you offer them a radio – that's unavailable so you give them a breakfast pack?" she said.

Ms Cound said Ricky's mistreatment was punishment.

"They were punishing my son, really. That was punishing him for the riot that happened at Acacia. He should never have been sent to Hakea because he had been sentenced and that's a remand centre," she said.

"Before he even left Casuarina, they knew he wasn't travelling well. His two oldest brothers were in jail. Why didn't they put my young boy with his two oldest brothers?

"You know, he was lost - his grandmother had died, and he was lost because of losses after losses in our family. We lost my mum and her sisters, one after another, and Ricky was very close with every single one of them. He wasn't travelling too well, trying to tell the system that, and they said 'no, he's not a child, he's an adult'. I was saying 'that's my baby'.

"Nobody looked on the on the alerts to see that he had FASD, no one. He was diagnosed with FASD in Banksia Hill."

Ms McShane said every death in custody made it fell like "it's happened all over again".

"Every time something like this comes up. The Coroner said to us, 'I hope you've got some answers, and it makes things easier'. No, it doesn't."

Ms Cound said she was considering getting legal representation to pursue justice for her son.

Ms McShane said late on Wednesday evening they were still working through the full Coroner's report.

"We've got to do what's best for Ricky and for the people that are now having to live life without him. His young nephew is here, he knows who Ricky is, he's got a life ahead of him and needs to be protected," she said.

She said her daughter only learned that the inquest findings had come down because she saw it online on the news.

"We still hadn't got the findings, we were waiting and waiting… But again, what else do we expect?"

Ms Cound said her son had pleaded for help multiple times.

"He didn't press that buzzer once, he pressed it several times and so did the other inmates. He said 'I don't want to hurt myself, put me under camera' and they were worried about sandwiches," she said.

Ms McShane said that two weeks before Ricky passed, her daughter had told her she was worried about him.

"She said 'he keeps asking for Megan Krakouer (Noongar justice advocate)'. I said, 'why?' and he had told her they'd put him in a dress, chained him up and made him sleep like that. That has never really come up. And I said 'ring Laura'." Ms Cound acted, making multiple calls to the prison to advocate for her son.

"If you have a look at the transcript of all the phone calls and the numbers at the end of his time at Hakea, they were hanging up on his calls so we could only talk for two minutes, and I could hear in my baby's voice that something had gone on with my son, and I rang back, and that's why I don't know why my phone calls are not on the transcript," Ms Cound said.

"I'm waiting patiently for justice for my Ricky. Ricky, he was only 22 years old. He was only a baby; he could have been still here. He asked for help."

Ms McShane said Ricky was up for parole on June 20th in 2022, and died in March.

"This hasn't … it doesn't actually help us at all, you think, 'okay, we've done that, now we've had the inquest, now we've got the findings," she said.

The Coroner, Mr Urquhart, was "not satisfied" that the care and management of Mr Cound's FASD was "appropriate".

His report found "the Department was responsible for that as the Department's Health Services were required to perform in an under-staffed and under-resourced environment within the prison estate".

The Coroner's report stated that although he "was satisfied some improvements and changes had been made by the Department since Mr Cound's death, a lot more still needed to be done to lower the risk of suicide amongst vulnerable prisoners, particularly those who are First Nations".

Mr Urquhart made eight recommendations in his report, with an emphasis on the treatment and care of prisoners with FASD and other disabilities, and on reducing the risk of suicide among prisoners.

"When is someone going to be held responsible and accountable? When? When are the changes going to happen? Because it's our First Nation people that are dying one after another, and there are young wedjella boys dying too," Ms Cound told National Indigenous Times.

"They got sent to jail, they got their judgement from the judge, they shouldn't be punished by the screws as well. But our people… They make it very hard in there for us."

Ms McShane said: "There are recommendations from this inquest, but there are recommendations from 35 years ago (from the Royal Commission) that have never gone into place."

"There have been slight changes since Ricky's death, but that's about all."

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