Governance is improving, but there is room for further progress

Since 2017, the Department has implemented a range of governance process improvements relating to the management of recommendations, internal audit activities and oversight practices.

Despite these changes, we still identified recommendations that had been closed with limited evidence of completion. We also identified opportunities to improve some processes and knowledge sharing to help prevent future deaths from occurring.

Frequent mental health recommendations highlight the crisis in prisons

Ten out of the 35 coronial recommendations related to improving the mental health care provided to prisoners. Mental health was also indirectly associated with many of the remaining 25 recommendations.

We tested four of these recommendations. We found the Department had made progress in some areas but remain concerned that some risks continue unmitigated.

Poor infrastructure increases risk of deaths in custody

Seven out of the 35 recommendations referred to infrastructure upgrades and investment. We tested two recommendations relating to ligature minimisation and other infrastructure changes at Broome Regional Prison and Casuarina Prison.

In both cases we found the Department made some progress to meeting the intent of the recommendations, but they were not fully implemented.

Limited staff training impacts both security and welfare 

Eleven of the 35 coronial recommendations related to prisoner management, including general staffing and training for officers. We tested four recommendations that focussed on mental health, suicide prevention and critical incident training for custodial officers. The other recommendation sought to balance welfare and security considerations.

All four recommendations led to some limited changes in practice.

Page last updated: April 12, 2023
Directed Review into the Department of Justice’s performance in responding to recommendations arising from coronial inquiries into deaths in custody