Barry Matt Stuart, 49, was taking medication while at Hakea prison in 2013, but needed to be reviewed by a psychiatrist before it could be decided whether he should continue with it.
There was a “severe shortage” of psychiatric appointments in WA prisons at the time, so he went several months without seeing one.
His prescription was repeatedly renewed, but at the end of October 2013 it was allowed to expire and he hanged himself in his cell weeks later.
Coroner Sarah Linton said in her findings publicly released on Tuesday that the lack of psychiatric review in a reasonable time contributed to Mr Stuart’s decision to take his life.
“More prompt psychiatric review and considered thought about his medication regime might have prevented his suicide,” she said.
The coroner recommended the Department of Corrective Services invest significantly more resources in ensuring prisoners are given regular access to psychiatrists, and that overall, an emphasis be placed on providing a more holistic approach to mental health care.
In a separate finding into the death of 20-year-old Aboriginal man Jayden Bennell, who hanged himself in a cleaning storeroom at Casuarina prison in March 2013, Ms Linton added to her recommendation.
“Efforts should also be made where possible to hire some Aboriginal mental health workers to form part of the mental health team,” she said.
Ms Linton noted Mr Bennell’s family saw the need for the recommendations of the Royal Commission into Aboriginal Deaths in Custody to be implemented.
“It is difficult, within the context of an isolated death, for me to consider many of these findings and recommendations and to make any assessment of what is necessary and practical,” Ms Linton said.
“I am aware the government has embarked on a widespread review of the coronial process in Western Australia, which will include specific consideration of procedures for death in custody investigations.
“Accordingly, I propose to refer both this finding and the submissions filed on behalf of Jayden’s family to the state coroner, who can consider them as part of all the overall process.
“I do not intend to imply that I endorse what is contained within those submissions, but I believe it is appropriate to refer them on so that they can be given due consideration.”
Mr Bennell was the grandson of playwright and boxer Eddie Bennell who was involved in establishing the royal commission more than 25 years ago.
Readers seeking support and information about suicide prevention can contact Lifeline on 13 11 14.
Suicide Call Back Service 1300 659 467.
MensLine Australia 1300 78 99 78.
Multicultural Mental Health Australia www.mmha.org.au.
Local Aboriginal Medical Service available from www.vibe.com.au.
This piece was originally published on ‘Perth Now’ March 14, 2017.