Inadequate supervision highlighted in inquest into death of Roebourne Regional Prison inmate Phillip Allen

An inquest into the death of Phillip John Allen, an inmate at Roebourne Regional Prison, has revealed significant shortcomings in the supervision of the 47-year-old prisoner on the night of his death. Allen was found in his cell on July 29, 2020, having taken his own life. Despite resuscitation efforts by custodial staff, he could not be revived. The inquest, mandated because Allen was under the care of the Department of Justice, aimed to scrutinise the quality of supervision, treatment, and care provided to him during his time at RRP, particularly concerning his mental health. Allen, remanded in custody on February 27, 2020, had exhibited concerning behaviour shortly after his arrival at RRP. Reports indicated he began expressing beliefs in “black magic” and spirits, prompting interventions by custodial staff. By May 6, 2020, Allen was placed on the department’s primary suicide prevention strategy, only to be shifted to a lower level of monitoring shortly after. Despite ongoing concerns about his mental health, including a diagnosis of delusional disorder, and repeated instances of erratic behaviour, including claims of being “sung”, Allen’s escalating distress seemed to fall through the cracks of the system. Being sung, sometimes also referred to as “pointing the bone”, is an Aboriginal custom whereby an elder is believed to have the power to call on spirits to do ill to another Aboriginal person alleged to have committed a crime or otherwise abused their culture. Tragically, on the night of Allen’s death, a crucial lapse in supervision occurred. While prison officers conducted regular cell checks and head counts, Allen managed to take his own life during the gap between the second and final check of the night. It was noted the officer conducting the final check failed to ensure all prisoners were accounted for, leading to the discovery of Allen’s body only upon unlocking the cell the following morning. The Coroner overseeing the inquest acknowledged the challenges posed by the COVID-19 pandemic and the resources available to mental health service providers within the prison. The Coroner was satisfied that the mental health care Allen received in RRP was appropriate and that his death was unexpected and would have been difficult to predict. However, the Coroner concluded the supervision during the final cell check was inadequate, further exacerbated by an inaccurate entry in the occurrence book suggesting a head count had been completed in all cells, misleadingly indicating adequate supervision. In response to the tragic incident, measures have been taken by the department to address structural points in cells which could enable prisoners to take their own lives, such as covering diagonal metal grilles in front of toilet cubicle windows. Additionally, plans are under way to cover similar grilles in common areas, with work scheduled to begin mid-2024. In light of the planned works, the Coroner did not consider it necessary to make a recommendation for such points to be rendered inaccessible to prisoners when they were in their cells. Lifeline: 13 11 14.