Mental health services in Western Australia's prisons remain under-resourced and inadequate as authorities ignore coronial recommendations, a deaths in custody report says.
A report into the WA Department of Justice's performance has found custodial staff are not properly trained and clinical staff are under significant pressure.
The Coroner's Court made 35 formal recommendations to the department between 2017 and 2021 following 13 inquests into the deaths of 17 prisoners in custody.
A report tabled in WA parliament on Monday examined how it dealt with 10 of the recommendations and if they will help prevent future deaths.
Inspector of Custodial Services Eamon Ryan found in several cases the department focused on closing recommendations, not implementing effective change.
"Unnatural deaths in custody are an absolute tragedy that have far reaching impacts for everyone involved, but none more so than for the families of those who pass," Mr Ryan said.
"While I feel the department takes seriously its responsibility to prevent future deaths in custody, it was disheartening to find many recommendations were closed with little evidence of any meaningful change to practices."
Many of the coronial recommendations related to improving the quality of mental health care provided to the 12 per cent of adult prisoners and young people in detention who were assessed as having a psychiatric condition or requiring further assessment for a suspected psychiatric condition.
Mr Ryan said mental health services for prisoners in crisis or with acute needs has been inadequate and often inaccessible for many years.
"This report confirms that despite several coronial recommendations, mental health services in prisons remain under-resourced," he said.
"Staff are not adequately trained in mental health care and clinical staff are under significant pressure."
Just over one third of all deaths in prison custody between 2000 and 2021 were people who identified as Aboriginal.
Mr Ryan said it was disappointing to find many support-based roles created in response to the Royal Commission into Aboriginal Deaths in Custody had not been filled.
"The department must ensure that (Aboriginal Visitor Scheme and Prison Support Officer) positions are filled across the prison estate if its role in preventing future deaths is to succeed," he said.
"One unnatural death in custody is one too many, but one that could have been foreseen and prevented is entirely unacceptable."
The Department of Justice has made improvements to its triage system and information sharing across health staff, Mr Ryan found.
It supported 11 of the 14 recommendations made in the report and will conduct an audit of all closed recommendations.
