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.

DOJ Response – Directed Review

Serco Response – Directed Review

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