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.
Recommendation 2
Track and disseminate ‘suggestions’ made by the Coroner.
Recommendation 3
Ensure PHS is adequately resourced for all prisons across Western Australia.
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.
Recommendation 5
Include mental health assessments by a qualified mental health practitioner in applications to place prisoners on a confinement order.
Recommendation 6
Physically locate mental health staff in management units.
Recommendation 7
Reconsider the Coroner’s recommendation to review light fittings in cells.
Recommendation 8
Ensure a minimum standard of infrastructure services is maintained at Broome Regional Prison until the new prison is built.
Recommendation 9
Remove ligature points in the minimum-security ablutions block at Broome Regional Prison.
Recommendation 10
Deliver anti-social personality disorder training to custodial staff.
Recommendation 11
Re-engage with the Mental Health Commission in an effort to secure contextualised and ongoing Gatekeeper training for custodial staff.
Recommendation 12
Ensure all senior officers receive regular critical incident management training.
Recommendation 13
Ensure AVS positions are filled across the prison estate.
Recommendation 14
Ensure criminogenic programs that are delivered demonstrate efficacy.