The Department of Justice has been criticised for not doing enough to act on coronial findings that could prevent deaths in custody across Western Australia.
There were 13 inquests into 17 prisoner deaths in WA between 2017 and 2021, with 14 detainees found to have died by suicide.
The Coroner's Court of Western Australia made 35 recommendations to the justice department following the inquests.
Ten of those were related to improving detainee access to mental health care, 11 made recommendations on staffing and training and seven referred to the need for infrastructure upgrades and investment.
In a report released on Monday, Inspector of Custodial Services Eamon Ryan said processes to manage recommendations have improved since the amalgamation of the departments of Correctives Services and the Attorney General in 2017.
Lack of follow-up 'disheartening'
But Mr Ryan said many recommendations were being closed with "little evidence" of implementation.
"It was hard not to form the view that in several cases the focus was more about closing the outstanding recommendation rather than implementing sustained change in a way that met the spirit and intent of the recommendation," he said.
"Coronial recommendations are about changing practices that reduces the risk [of deaths in custody], and where they were closed and subsequently there would be no follow-up action, it was disheartening to see that.
"Despite several coronial recommendations, mental health services in prisons remain under-resourced. Custodial staff are not adequately trained in mental health care and clinical staff are under significant pressure."
The report outlined 14 findings to improve the implementation of coronial recommendations and prevent harm to detainees.
Eleven findings have been accepted, with a recommendation to physically locate mental health staff in specialised health units rejected due to resource constraints.
The report recommended removing ligature points in the minimum-security ablutions block at Broome Regional Prison, but the department said the facility was not included in its current ligature minimisation project.
Department places 'great importance' on findings
In its response to the review, the department said it works with the coroner to identify solutions to recommendations that are achievable "within resourcing capabilities".
Department Director General Adam Tomison said "great importance" was placed on coronial recommendations.
"We've established a Lessons Learned process which identifies immediate actions and opportunities to enhance the safety of people in custody and reduce the likelihood of unnatural deaths," he said.
Corrective Services Commissioner Mike Reynolds said a suicide prevention strategy and governance unit had been initiated to better manage at-risk and vulnerable prisoners.
"We're also working hard to bolster mental health care for prisoners, including the development of dedicated units in two prisons and regular training in this area for prison officers," he said.
