A West Australian coroner has strongly criticised the lack of "safe"cells at Acacia prison, describing the situation as "incomprehensible".
Warning: Aboriginal and Torres Strait Islander readers are advised that the following story contains the name and image of a person who has died.
Coroner Philip Urquhart made the comment at an inquest into the suicide of 30-year-old Jomen Blanket, who was found dead in his prison cell in June 2019.
On Wednesday, the Perth jail's former prisoner risk assessment officer, Anna Francis, gave evidence at the hearing.
Ms Francis said it was her job to ensure the facility was safe for prisoners.
She told the inquest that only six of the 1,000 prison cells at the centre were deemed "safe" or "ligature-minimised", and none were "ligature-proof".
Mr Urquhart said he found it "incomprehensible that a prison built today would only have six ligature-minimised cells".
Ms Francis also told the hearing that, at any given time, there would be eight to 12 prisoners at Acacia who were at some risk of self harm.
The coroner said he was deeply concerned about those figures.
"I am concerned. I'm concerned about this because it's a repeat of an inquest a couple years ago," he said.
Ms Francis said that, although there were new cells being built during her time at the prison, they were not safe cells and were not any safer than the older cells at the facility.
She also said she was concerned that new prisoners would use design of the new, two-storey block to self harm.
Ms Francis said that, while there were discussions about how the new cells could be made safer, nothing had eventuated.
She was also concerned that, although staff had access to mental health and suicide training, there was a lack of Indigenous cultural awareness training.
"It would be helpful for staff to understand the link between cultural and psychological issues," she said.
Social worker visit delayed
Earlier in the day, social worker Michael Saligari continued giving evidence.
Mr Saligari said that, on the day of Blanket's death, he was told the young man wanted to speak to him, which he thought was "bizarre" and out of character.
But Mr Saligari said because he had been told Blanket was in the process of being transferred to a safe cell, it was "almost impossible" to see him for an assessment at the time.
He said he instead set up an appointment to see Blanket at midday, when he would be "more settled" in his new cell.
"I assumed there was no possible way he'd be at risk, knowing he was being moved to a safe cell," he said.
Blanket was found dead less than an hour later, before he was able to be moved to a medical observation cell.
Mr Saligari told the court he believed he had "acted with extreme caution" … and, in that moment, he thought the young man would be safe.
"I gave it my utmost best. I was very active in advocating for Mr Blanket. I believe I performed very well. I'm comfortable with my decision and what I did," he told the inquest.
He also told the court he was not aware that Blanket had told his mother several months earlier about wanting to kill himself, and that information would have been helpful.
Mr Saligari told the court Blanket had displayed potential evidence of psychosis due to self-harming ideations and signs of major mental illness.
He also had been hearing voices and was experiencing "spiritual" issues.
Blanket's death preventable
The family's lawyer, Steven Penglis SC, raised concerns over Mr Saligari's decision to lower Blanket's monitoring from high to moderate risk, in light of those mental health issues.
The inquest was told about other instances in which Blanket had told staff he wanted to end his life.
It also heard that a mental health report, dated about a month before Blanket died, said he had attempted to kill himself 10 times before — and that it was information Mr Saligari was privy to.
Blanket had also asked to be placed into Graylands Hospital, a psychiatric facility, but was told it would be unlikely.
Towards the end of his evidence, Mr Saligari conceded that Blanket's death was predictable and preventable on the basis he had expressed to staff his plan to kill himself.
"Because he made some distress visible, I thought it would be preventable," he said.
Mr Saligari conceded that, in hindsight, he should have placed Blanket under constant surveillance.
The inquest has been adjourned until December.
