WARNING: This story contains distressing elements, including references to suicide.
Suicide prevention experts believe failure to take cultural care seriously in prisons is costing lives.
And, they say, if the federal government were to allow Medicare access to prisoners it could help prevent further tragedy.
In the days leading up to the death of Aboriginal teenager Stanley Inman Jr at Acacia Prison in Western Australia, he was crying out for help.
His mental health was deteriorating.
He had reported self-harm and been under observation.
He cancelled a planned visit from his mother and made multiple phone calls in which he disclosed the depths of his despair.
But, after seeing two different psychologists in two days, both of whom downgraded his risk, Mr Inman was sent back to his cell.
He killed himself the next day.
National Suicide Prevention & Trauma Recovery Project director Megan Krakouer said had Mr Inman been given access to culturally appropriate care, his death could have been prevented.
"Had Stanley received the correct supports from Aboriginal people on a daily basis, where there was a need for cultural integrity and cultural connectivity, he would still be alive," she told AAP.
"It would have meant ensuring that that system is not so inhumane and there could have been a facilitation of phone calls with his mum, Connie.
"Another young person is now lost and his family is forever mourning."
When Mr Inman was taken into remand in Hakea on February 19, 2020, he disclosed to staff that he had attempted to take his own life two months earlier, following his brother's death.
He denied suicide ideation but the prison medical officer noted "stress" and as a matter of standard procedure for young people, he was assessed under the at-risk management system, which required four-hourly monitoring for seven days, but he was not treated by a psychologist.
After being sentenced, Mr Inman was sent to Casuarina, then transferred to Acacia, a private prison run by Serco.
From July 4 to 8, 2020, Mr Inman made numerous phone calls to his mother and his partner in which he expressed suicidal ideation.
Detainees' phone calls are routinely recorded, but none of the staff tasked with assessing Mr Inman's psychological state or the group that oversees them asked for or received the records as part of their assessment.
On July 8, 2020, Mr Inman told staff he had been self-harming.
He was again placed on the at-risk management system and moved to an observation cell.
National Justice Project chief executive George Newhouse, Stanley Inman’s sisters Jacinta Miller and Tianna Austin and mother Constance Moses speak to media. Source: AAP / Aaron Bunch/AAP Image
Coroner Michael Jenkin concluded that, although the management of Mr Inman's general health was appropriate, the overall quality of his supervision, treatment and care was of a lower standard than it should have been.
"In my view, this occurred because Mr Inman's background risk level was not properly appreciated when he was first admitted to Hakea," the coroner's report read.
"Notably he did not see a psychologist or counsellor from that time until July 9, 2020."
The Department of Justice's Health Review after Mr Inman's death found identifying Mr Inman as having a higher background risk of suicide in the context of acute family stresses or losses would have been "helpful".
But, the coroner said, had the content of Mr Inman's calls been known by those tasked with making decisions about his welfare it was almost inevitable he would have been the subject of a greater level of scrutiny for a longer period.
"Further, instead of viewing Mr Inman's self-harming behaviour (which he disclosed on July 8, 2020) as a discrete incident, the content of his calls to his mother and partner would have identified that his distress in the period leading up to his death was far more acute than was appreciated," he said.
Ms Krakouer said the coroner's report, which did not make any recommendations on the basis that Acacia had changed its scrutiny of prisoner phone calls and mail, wasn't good enough.
"We've seen in many cases when there's Aboriginal people who have been failed, recommendations be put forward and lack of action, lack of implementation, and therefore it is tragically getting worse," she said.
"They failed this kid, they failed his family and they failed our community.
"Those recorded telephone calls, those pieces of information, which were vital, were not provided to the prisoner risk assessment group and that is a massive fail.
"He had attempted suicide in the community and had presented at hospitals so where was the sharing of the information between the health system and the Department of Corrective Services?"
Following Mr Inman's death, Ms Krakouer and other suicide-prevention professionals were engaged to work at Acacia.
"We'd go into all the units and just provide that love, that kindness, that support that respect," she said.
"And because we're known in community, we have resonance.
"Within one quarter, we'd taken self harms down from 33 to three with the approach that we use."
Ms Krakouer also points out that at the time of Mr Inman's death, the Aboriginal visitors' scheme wasn't in operation at Acacia.
"It's actually a grave injustice and an indictment on the WA government," she said.
And Ms Krakouer called on the federal government to amend legislation to enable detainees access to Medicare, which would mean Aboriginal Medical Services across the country would be able to go into the prison system.
"Right now it is health discrimination at its best," she said.
A spokesperson for the federal health department said Indigenous people should receive adequate and culturally safe health care if they are in prison, but responsibility for providing it lies with the states and territories.
Acacia Prison in Wooroloo is a private facility run by Serco Australia. Credit: WA Police
A Serco spokesperson said the company was considering the coroner's report and following Mr Inman's death they had enhanced support services and management of prisoners who pose a risk to themselves.
The spokesperson said a mental health and psychological services team at Acacia Prison is supported by culturally-safe programs and services for First Nations people.
WA Corrective Services Minister Paul Papalia was approached for comment.
13YARN 13 92 76
Aboriginal Counselling Services 0410 539 905
Lifeline 13 11 14
beyondblue 1300 22 4636
