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“Perfect storm’ led to death of Indigenous inmate
A WA coroner has made eight recommendations to the prison system after making public his findings into the death of Ricky-Lee Cound at Hakea Prison three years ago.
Coroner Philip Urquhart said he found a ‘perfect storm’ of circumstances that led to the death of Mr Cound who arrived at the prison after being transferred from Acacia Prison following a riot.
Mr Cound had been placed on an At Risk Management System because of his history of mental illness, self-harm and threats of suicide.
But he was taken off the plan three hours before he died from self inflicted injuries.
Mr Cound was also diagnosed with Foetal Alcohol Spectrum Disorder, something found to have contributed to his death.
The prison was in a chaotic state due to a covid outbreak and Mr Cound was one of 170 inmates suffering from the virus.
One officer described the situation as “panic” as the virus spread through the jail.
On the day of his death Mr Cound asked to be placed in a cell with CCTV for his own safety- but this did not happen.
It emerged that broken glass from a window had not been cleared away and a prisoner called out that there “was blood everywhere”.
Coroner Philip Urquhart said Ricky-Lee Cound should have been moved to a safe cell.
Mr Cound could not be revived by staff and was later pronounced deceased at Fiona Stanley Hospital.
The Coroner said Mr Cound should have been placed back on the program after his call for help, and that “contributed to his death.”
“Had he been in a safe cell, the risk of Cound being able to end his life would have been significantly lower than the level of risk that existed within his cell in B Wing,” Mr Urquhart found.
The coroner said some improvements had been made since the death, including body cameras worn by staff.
He also said officers should undertake mandatory training on how to manage Foetal Alcohol Spectrum Disorder.
Mr Cound’s mother Santana Cound said in a statement read to the court her son’s death had caused “a lot of heartache and pain”.
“We’re on Aboriginal land. And yet our boys keep dying in this criminal system,” the statement read.
