Under Section 17(2)(b) of the Inspector of Custodial Services Act 2003 (WA) the Minister for Corrective Services can direct the Inspector of Custodial Services ‘to review a custodial service in relation to a prison or detention centre or a custodial service (CSCS Act) or an aspect of that service’.

On 24 September 2021, the Inspector accepted the direction by the Minister for Corrective Services, Hon. Bill Johnston MLA, to undertake a review of the Department of Justice’s (the Department’s) performance in responding to recommendations that arise from the Western Australian Coroner’s inquiries into deaths in custody. On 11 November 2021, the Minister endorsed the draft terms of reference to examine deaths publicly reported on between 2017 and 2021 to determine the following:

  • Does the Department implement recommendations made by the Western Australian Coroner appropriately?
  • How effectively does the Department monitor its continued compliance with the recommendations made by the Western Australian Coroner?

The approach we took

Between 2017 and 2021, the Coroner’s Court made 35 formal recommendations to the Department. One recommendation was noted and only one recommendation was not supported. The 35 recommendations were from 13 requests relating to 17 prisoners. Only two of these people were determined to have died from natural causes. One person died by way of an accident and the other 14 were determined to have been suicides.

To answer our terms of reference, we randomly tested a sample of 10 of the 35 coronial recommendations directed to the Department, that were then supported, actioned, closed and verified. To test these recommendations, we requested the Department’s closure evidence for each.

Page last updated: April 20, 2023

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