Case File: Inquest into the Death of Mr Jackamarra

WARNING: First Nations readers are advised that this case summary contains names of deceased persons.

WARNING: This story contains detail that may be distressing to some readers, including descriptions of suicide. If you are experiencing distress and are in need of support, please contact Lifeline on 13 11 14.

Case name:

Inquest into the Death of Khamsani Victor Jackamarra, Coroner’s Court of Western Australia (9th May 2019)

Case summary:

After being kept in custody while awaiting bail monies to be provided the next day, 36-year-old Aboriginal man Khamsani Victor Jackamarra took his own life at Broome Regional Prison.

Mr Jackammara had suffered from personality disorders and had frequently been admitted to mental health services. However, this important personal information was mishandled by SERCO officers and prison support officers, who expressed no concern for his welfare in the lead up to his death.

The facts:

On 16 December 2015, Mr Jackamarra pleaded guilty to charges at Broome Magistrates Court. He was granted bail, but on the condition that another person attend Court to agree to provide money for his bail (known as a surety). Because the nominated surety was not able to make an appearance in court to sign the surety papers that day, Mr Jackamarra was kept in custody.

The Coroner noted that his offences reflected his substance abuse issues and his pshycological illnesses. Mr Jackamarra suffered from personality disorders and was prescribed medication for this illness and had been frequently been admitted to mental health services.

While attempts were made to contact Mr Jackamarra’s surety, he was held in the Custody Centre attached to the Court. Mr Jackamarra also told the officer that he needed to take his daily anti-depressant medication. This vital information, however, was not recorded in the prison system.

At 11:35 am a SERCO officer found Mr Jackamarra banging his head against the cell wall and he requested to be transferred to Broome Regional Prison. When Mr Jackamarra was assessed at the prison, the prison intake officer was not made aware of his welfare or state of mind. The prison support officer he spoke to saw that he appeared upset, but after they spoke the officer showed no concern for his welfare.

After this, Mr Jackamarra requested a shower at 1:30PM, and at 2:10PM a prisoner informed officers that a person had hanged themself in the showers. The officers tried to resuscitate Mr Jackamarra, but he was unresponsive.

The legal issue

A mandatory Coronial Inquest was held as a consequence of Mr Jackamarra’s death while in custody of the Western Australian Department of Corrections. The Department investigated their policies and procedures, especially in regards to the potential of self-harm for those in custody and found that there had been a lack of compliance with facilitating information about the behaviour of prisoners between different custodial settings.

SERCO guards did not inform staff at Broome Regional Prison about Mr Jackamarra’s distress or mental health condition. He was not identified as being at risk of self-harm, even though he had mental health risks and alerts whilst in prison many times, and significant mental health conditions and hospital presentations whilst in the community. The Coroner looked at implementing and improving the custodial system to provide safety to those transitioning through different systems.

What was held:

The Coroner made recommendations to help ensure that the appropriate services are available to prisoners with mental health conditions, and urged authorities to improve prison counselling, medical services, and information sharing between prisons.

The Coroner also recommended that CCTV coverage should be extended and improved to help avoid issues to do with prisoners’ welfare, as well as implementing prison officer training to deal with inmates who have previously attempted or are at risk of self-harm.

The Coroner noted that prisoners should be actively involved in caring for each other, and that by promoting welfare and security as mutually-reinforcing outcomes, the prison system can better ensure that prisoners with disabilities or mental health disorders get appropriate support and services.

Finally, the Coroner noted that suicides in prison can rapidly become a security issue in itself, as suicides in prison are distressing for all concerned, including staff, other prisoners and the community.

In the media

Author: Yewande Alabi




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