Stanley Inman: WA Coroner’s findings highlight prison failure to provide cultural care to Aboriginal inmates

A WA Coroner has found that the care provided to an Indigenous teenager who took his own life in Acacia Prison was of “a lower standard than it should have been”, and that he could have been saved had culturally-safe care been provided to him. Stanley John Inman was found unresponsive in a storeroom at the Serco-run prison on July 11, 2020. He passed away in hospital two days later. In the days leading up to his death, the 19-year-old had self-harmed several times and told his family members over a series of phone calls that he wanted to die. Stanley also later told a staff member that he had been cutting himself. He was subsequently put on hourly supervision as per the prison’s At Risk Management System (ARMS) on July 8, which was downgraded to two-hourly checks the following day. On July 10, Stanley “denied self-harm or suicidal ideation” to psychologist Michael Waine, and his risk was reduced to low ARMS, meaning he only required checks every four hours. A coronial inquest into Stanley’s death, held over two days in May this year, scrutinised the level of care available to Indigenous people in custody. Mr Waine told the inquest that had had not been aware of the contents of the alarming phone calls Stanley had made to his mother and partner before his death, and that “even knowing the volume of calls he was trying to make … would have influenced a consideration of risk”. In his findings, delivered last month, Coroner Michael Jenkins concluded that although the management of Stanley’s general health in Acacia Prison had been “appropriate”, the overall quality of his supervision, treatment and care was of “a lower standard than it should have been”. Mr Jenkins said staff had not properly appreciated Stanley’s background risk level when he first arrived at Acacia, and that as a result the true risk he was at was not properly understood. He also found that had the content of the many phone calls Stanley had made to his loved ones in the days before his death been assessed at the meetings where his level of risk was assessed, “he would have been provided a greater level of support”. The inquest in May was told that since Stanley’s death, Acacia Prison had begun taking the mail and recorded phone calls of prisoners who are on ARMS into consideration during assessments about suicide risk. “Had the content of Mr Inman’s phone calls been assessed. . . on 9 July 2020 and 10 July 2020, it is almost inevitable that he would have been the subject of a greater level of scrutiny for a longer period,” Mr Jenkins wrote in his findings. “Further, instead of viewing Mr Inman’s self-harming behaviour (which he disclosed on 8 July 2020) as a discrete incident, the content of his calls. . . would have identified that his distress in the period leading up to his death was far more acute than was appreciated.” Since Stanley’s death, the storeroom he was found unresponsive in — which prisoners previously had access to — has also been secured. Responding to the expert analysis of culturally safe care in WA Prisons by Professor Pat Dudgeon, the director of the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention, the coroner wrote that had culturally safe care been available at Acacia at the time of Stanley’s incarceration, he may have been saved. “It is also possible that had the culturally safe care. . . been available at Acacia, Mr Inman’s life journey may well have been different,” he wrote. “I strongly encourage both Acacia and Department of Justice to carefully review the recommendations outlined in Professor Dudgeon’s report.” National Justice Project chief executive George Newhouse, who represented Stanley’s family at the inquest, said it was clear the WA Government did not prioritise culturally-safe care for First Nations people in custody. “First Nations prisoners, advocates and communities have told the Government tirelessly that culturally-appropriate healthcare delivered by Aboriginal Medical Services would help prevent the abhorrent rates of deaths in custody,” he said. Megan Krakouer, director at the National Suicide Prevention and Trauma Recovery Project, said the findings showed that the State’s largest prison was not being serviced by an Aboriginal Visitors Scheme — a failure that was denying hundreds of Indigenous people psychosocial support. “Stanely Inman Jnr was failed by a system that was supposed to rehabilitate and protect him until he could come out be with his family,” she said. “Instead, Stanley was shown disrespect and a lack of care by WA Corrective Services.” Lifeline: 13 11 14 If you or someone you know needs help, phone SANE Australia Helpline on 1800 18 SANE (7263)