An Aboriginal man who died in custody in Western Australia’s Casuarina prison received “inadequate” mental healthcare in the months leading up to his death, a coronial inquest has found.
Jayden Stafford Bennell, a Bibbulum Noongar man from Perth, was 20 years old when he was found dead in a cleaning storage room at the prison on 6 March 2013.
Bennell had been in and out of prison since he was 14 years old and been in custody continually since 30 April 2012. At the time of his death he was awaiting sentencing at the supreme court and expecting to receive a lengthy term of imprisonment of up to eight years.
A coronial report into his death, released on Tuesday, ruled his death as a suicide.
In the only recommendation made in the 59-page report, coroner Sarah Linton, who presided over a four-day inquest into Bennell’s death in August and September last year, recommended the Department of Corrective Services “invest significantly more resources” in giving prisoners regular access to psychiatrists, place an overall emphasis on a “more holistic approach to mental healthcare” and endeavour to employ Aboriginal mental health workers.
She made an almost identical finding following an inquest into the death of a 49-year-old man who took his own life at Perth’s Hakea prison in November 2013. The report into that inquest was also released on Tuesday.
Linton did not make any recommendations about systemic issues raised in submissions by lawyers for Bennell’s mother, Maxine Bennell, instead referring them to the state coroner for consideration as part of an overarching review of coronial services.
She also did not recommend the prison end access to the storage room where Bennell took his own life despite finding it the “option of least risk”, accepting evidence from prison management that locking the door would be “impractical”.
Bennell was the oldest of seven children, not including a stillborn twin brother. He was raised by his mother and witnessed her abuse at the hands of a violent partner. He left school in year eight and became involved in lower-level criminal offences after a family member showed him a photo of his twin, which his mother described as a traumatic experience.
His criminal behaviour escalated after his first stint in juvenile detention.
He began seeing a psychiatrist just before his 17th birthday and reported symptoms of agitation, insomnia, visual and auditory pseudohallucinations, and paranoid thoughts. He was given antipsychotic medication and diagnosed first with drug-induced psychosis and then with an adjustment disorder, but neither diagnosis stuck.
In August 2010, after he had again been sent to prison, this time to an adult jail, Bennell saw a psychiatrist called Dr Mark Hall, who told the inquest he was unable to determine the exact nature of Bennell’s condition despite seeing him 15 times over two years, always while Bennell was detained at Hakea prison.
Hall said Bennell had a tendency to “catastrophise” about the future and classified him “in the ultra-high risk group for development of a psychotic disorder”.
Bennell last saw Hall in August of 2012, three months before being moved from Hakea prison to Casuarina prison. He was not admitted to see another psychiatrist in the seven months between that appointment and his death, a gap Linton found “inadequate”.
“Given Jayden’s known history of ongoing psychotic symptoms and lack of a clear diagnosis despite a reasonable period of treatment, and his ongoing refusal to take his medication, it was important for Jayden to have been seen by a psychiatrist within a reasonable period of time after his transfer to Casuarina, and out of Dr Hall’s ongoing care,” Linton said. “I do not consider seven months to be a reasonable period of time for Jayden.”
A mental health nurse did make a booking for Bennell to see a psychiatrist on the afternoon of 6 March, 2013; after his body had already been found.
Bennell’s cellmate and friend, Craig Scortaioli, told the inquest he had seemed “a bit depressed” in the week leading up to his death and had previously had a vision of himself hanging, after inhaling fumes from printer fluid.
He had hugged Scortaioli goodbye on the morning when the latter left on work duties on the morning of the sixth, saying “I love you, my brother. I will see you later.”
Bennell attended an Aboriginal drug and alcohol support program called Pathways that morning and spent the lunchtime lockdown, from 11.45am to 1.15pm, alone in his cell. He was due to return to the program at 1.30pm but instead attempted to phone his brother at 1.26pm, then disappeared.
When Scortaioli returned to the unit at 1.39pm the door to their shared cell was open and a song that Bennell had previously said he wanted played at his funeral was playing on a loop. Ten minutes later, after making a phone call, Scortaioli returned to find the room in disarray, a bedsheet ripped in half, and an exercise book later discovered to contain a suicide note sitting on top of the stereo.
Ben Moodie, who managed the Pathways program, gave evidence at inquest that he had asked the guards three times to look for Bennell that afternoon, starting at 1.35pm. However none of the guards remembered talking to Moodie about Bennell that day, and there was no record of the alarm being raised.
Moodie was not interviewed by either police or coronial investigators and did not give a statement until February 2016, which lawyers for Maxine Bennell said pointed to the inadequacy of the coronial investigation. Linton dismissed suggestions the investigation was inadequate and said while she found Moodie to be an honest and genuine witness, the delay coupled with the fact that no one else corroborated his evidence meant she found it unreliable.
Bennell was not officially noted as missing until 3.15pm, when he was unable to be found after failing to appear at muster. After a second muster was called at 3.44pm a prison guard noticed the door to the cleaning storage room opposite Bennell’s room was ajar, and located his body inside.
Linton found that it was “highly likely that Jayden was deceased by the time Mr Scortaioli had finished his telephone call”.
She said it was of “great concern” that officers took two hours to find Bennell’s body, despite it being in a “commonly used area”, saying: “It must be very distressing for Jayden’s family to know that his body took so long to be discovered.”
However she did not find the storeroom should be locked, accepting evidence from Steven Southgate, assistant commissioner for the prison, that it was important for prisoner autonomy that prisoners be able to access cleaning materials stored in the room to clean their own cells.
The prison did not restrict access to the room until a week before last year’s inquest, and it is still unlocked for three hours every morning.
Of the 19 similar suicides at Casuarina prison between 2000 and 2016, the report found, Bennell’s was the only one to occur outside a cell.
• Crisis support services can be reached 24 hours a day: Lifeline 13 11 14; Suicide Call Back Service 1300 659 467; Kids Helpline 1800 55 1800; MensLine Australia1300 78 99 78