The Department of Corrective Services should consider investing “significantly more resources” into prisoners’ access to psychiatrists, according to coroner Sarah Linton.
Ms Linton today released her findings into the deaths of two prisoners who took their own lives while behind bars.
Barry Matt Stuart died at Hakea Prison in November 2013 after his prescription for the drug olanzapine expired.
The drug appeared to help Mr Stuart cope in jail but he lost access to it after he went months without a psychiatric appointment.
Ms Linton found the psychiatric care provided to Mr Stuart was less than the expected standard for a prisoner who could not independently access medical professionals.
“I find that the lack of psychiatric review in a reasonable time period contributed to the deceased’s decision to take his life,” she wrote in her findings.
“In the sense that more prompt psychiatric review and considered thought about his medication regime might have prevented his suicide.”
Eight months before Mr Stuart’s death, Aboriginal prisoner Jayden Stafford Bennell also took his own life in Casuarina Prison.
Mr Bennell’s death came as a great shock to his family, who had no prior warning that he was experiencing suicidal thoughts.
Despite his history of ongoing psychotic symptoms and refusal to take medication, Mr Bennell did not see a psychiatrist in the seven months leading up to his death.
Ms Linton described the mental health care given to Mr Bennell in prison as inadequate, saying the failure to give him access to a psychiatric was a “lost opportunity”.
“I accept that the availability of psychiatrists at Casuarina has improved since Jayden’s death,” Ms Linton wrote.
“However, I also accept the evidence of Dr Brett that on the whole, mental health treatment in WA prisons remains under resourced and underfunded.”
Ms Linton recommended the department invest more resources into ensuring prisoners are given regular access to psychiatrists when planning for the future.
She also said a more holistic approach to mental health care in jail should be adopted and efforts should be made to hire Aboriginal mental health workers where possible.