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WA Coroner finds culturally safe care in prison “may well have” saved young Indigenous man’s life

A Western Australian coroner has accepted expert opinion that the life of Stanley Inman Jnr, a Noongar and Wirlomin man who died in Acacia Prison at nineteen years of age, could have been saved if there had been culturally safe care provided to him.

Mr Inman Jr was found unresponsive in a storeroom at Acacia, near Perth, on July 11 2020, the day after a psychologist and a risk assessment team reduced his level of supervision for the second time in two days. He passed away in hospital two days later.

A coronial inquest into Mr Inman’s death was held from 9-10 May this year.

Coroner Michael Jenkin’s findings drew attention to the “discouragingly low” [Paragraph 124] number of First Nations staff employed at Acacia Prison (20 out of a total of 325 staff), and he said “it is disappointing that the Aboriginal Visitors Scheme (AVS) ceased at Acacia in April 2022, when the AVS visitor resigned” [Paragraph 127] after Mr Inman’s death.

Responding to an analysis of culturally safe care in WA Prisons from Professor Pat Dudgeon, Director of the Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention, the coroner wrote:

“I strongly encourage both Acacia and Department of Justice to carefully review the recommendations outlined in Professor Dudgeon’s report.”

Coroner Jenkin concluded, in paragraph 139, that “It is also possible that had the culturally safe care referred to in Professor Dudgeon’s report been available at Acacia, Mr Inman’s life journey may well have been different”.

“The overall quality of Mr Inman’s supervision, treatment and care was of a lower standard than it should have been because his level of risk was not properly understood,” he wrote in paragraph 133.


If you or someone you know needs help or support, you can contact your local Aboriginal Community-Controlled Organisation or

  • 13YARN: 13 92 76
  • Lifeline: 131 114
  • Kids Helpline: 1800 551 800
  • Mensline: 1300 78 99 78
  • Beyondblue 1300 22 46 36
  • Q Life 1800 18 45 27
  • Open Arms Veterans & Families Counselling 1800 01 10 46
  • The National Indigenous Critical Response Service 1800 80 58 01
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