A coronial inquest into the death of a 19-year-old man who took his own life at Acacia Prison in 2020 has heard psychologists downgraded his suicide risk in the days before he died.
WARNING: This story contains the image and name of an Indigenous person who has died.
Stanley Inman Jr was found unresponsive in a storeroom at the prison near Perth on July 11, the day after a psychologist and a risk assessment team reduced his level of supervision for the second time in two days.
The frequency of checks on Stanley, whose family asked for him to be referred to by his first name, had been reduced from one-hourly on July 8 to four-hourly on July 10.
His family told reporters outside Perth Central Law Courts on Tuesday it was "shattering" to learn the details of his final days, including the emotional testimony of a prison guard who tried to save Stanley's life.
"We've had to sit in there and hear that a lot of things changed after the fact," Jacinta Miller, Stanley's sister, said.
"For another family [it] is something good, but for us it's not good to hear."
A packed courtroom heard Stanley had been in custody for about four months when he started to show signs of emotional distress in July, 2020.
Content of phone calls not considered
On July 8 he made repeated references to self-harm and suicide during phone calls with his partner, before cutting himself and telling a prison guard he wanted to kill himself.
He was put under hourly supervision through the prison's At Risk Management System (ARMS), but that was downgraded the next day to two-hourly checks.
On July 10, after Stanley's risk status was reviewed by psychologist Michael Waine, his level of risk was again reduced to "low" and the number of checks dropped to every four hours.
Mr Waine told the court Stanley had denied he was suicidal or at risk of self-harm.
He said he was unaware of Stanley's references to suicide and self-harm in phone calls with family.
"Even knowing the volume of calls he was trying to make … would have influenced a consideration of risk," Mr Waine said.
The prison has since started considering recorded phone calls during assessments about suicide risk.
Family says better systems needed to report concerns
Stanley's sister, Ms Miller, told reporters her family had tried to alert the prison of their concerns about his mental health.
"When you call the prison, there's several times where you can't actually get through," she said.
"We contacted them … their lack of cultural awareness too kind of contributed to us not being listened to."
Acacia prison officer Nicholas Manifis said Stanley had confided in him that he was not coping after the death of his brother.
But he said he saw the 19-year-old hide those feelings in front of other prison staff.
Mr Manifis became visibly emotional as he recalled the moment he found Stanley, who had failed to report at his cell for a routine prisoner count.
Speaking directly to the family, he said he was sorry for their loss.
"You know I am," he said, before a member of Stanley's family hugged him.
The family, represented by lawyers from the National Justice Project, called for a list of urgent reforms to prevent future deaths and provide better mental health care in prisons.
Tianna Austin, Stanley's other sister, made an impassioned plea to introduce culturally-safe medical services and a well-funded elder support program at all WA prisons.
"We want to see reports of self-harm made by prisoners taken seriously," she said.
"And we want a system for family to report their concerns, complain about treatment, or ask for support — where they are listened to."
In response to questioning from Coroner Michael Jenkin, Mr Manifis and fellow prison guard Kate Moore both agreed that more frequent "scenario" training would be beneficial to officers responding to suicides.
Coroner Jenkin questioned the prison guards about the locking mechanism on the door of the storage room, which was left open every day, and asked about the "quality" of checks on at-risk prisoners.
He said some hourly checks appeared to be only observations of what the inmate was doing, rather than verbal check-ins.
Ms Moore said the officers had to balance their interactions with the prisoners during those checks to avoid unwanted disruptions that could be more distressing.
'System failed'
As the second day of the inquest wrapped up, the family said they hoped the coronial inquest would lead to real change to prevent other families having to endure losing a loved one in the same way.
They made a number of recommendations including implementing a procedure requiring significant risk factors, such as self harm and health issues, to be "flagged" within the Total Offender Management System.
The court also heard a statement from Ms Miller, who said the system had failed Stanley and his family.
They were left in tears as the inquest came to an end and heard the findings from the inquest would take months.
