Inquest into the Death of Sean Theo WINMAR (Mr STW)

[2026] WACOR 3 JURISDICTION : CORONER'S COURT OF WESTERN AUSTRALIA ACT : CORONERS ACT 1996 CORONER : SARAH HELEN LINTON, ACTING STATE CORONER HEARD : 22 JANUARY - 23 JANUARY 2025 DELIVERED : 23 JANUARY 2026 FILE NO/S : CORC 2208 of 2022

DECEASED : WINMAR, SEAN THEO Catchwords: Nil Legislation: Nil Counsel Appearing: Mr W Stops assisted the Acting State Coroner.

Ms O Roberts and Ms B Yarran (ALSWA) appeared on behalf of Ms Kerry Ann Winmar.

Ms K Reynolds appeared on behalf of Dr Sean Hodgkinson (Homeless HealthCare).

Ms R Panetta (SSO) appeared on behalf of the WA Police Force and the Department of Justice.

Case(s) referred to in decision(s): Nil

[2026] WACOR 3 Coroners Act 1996 (Section 26(1))

RECORD OF INVESTIGATION INTO DEATH I, Sarah Helen Linton, Acting State Coroner, having investigated the death of Sean Theo WINMAR with an inquest held at the Perth Coroner’s Court, Court 85, CLC Building, 501 Hay Street, Perth on 22-23 January 2025, find that the identity of the deceased person was Sean Theo WINMAR and that death occurred on 11 August 2022 at Sir Charles Gairdner Hospital from complications of ligature compression of the neck (hanging) in the following circumstances:

TABLE OF CONTENTS SUPPRESSION ORDER That there be no reporting or publication of Chapter 10 and Chapter 16 of the Adult Community Corrections Handbook on the basis that it would be contrary to public interest.

[2026] WACOR 3 INTRODUCTION

1. Sean Theo Winmar, (Mr STW)1 was a Whadjuk and Ballardong Nyungar Aboriginal man who enjoyed travelling to places across Nyungar country and spending time with his family.2 He was born in 1976 and was 46 years old at the time of his death.

2. Mr STW reported he had a relatively happy early childhood, growing up in a big, loving family. Unfortunately, he developed behavioural problems at school and began abusing substances in his early teens. There was a suggestion in the evidence that his substance use issues could have been associated with exposure to violence, alcohol and drug use in his childhood, although Mr STW attributed his behaviour to rebelling against a relatively strict Christian upbringing. Mr STW began to commit offences as he grew older, and drug and alcohol use featured in all of his offending.3

3. As an adult, Mr STW was in a long-term significant relationship and had three sons with his partner. The relationship was said to be volatile and impacted by substance misuse, mental health issues and violence. As a result of the problems in the relationship and time he spent in custody, Mr STW was not always able to be physically present in his children’s life, but he continued to love them and tried his best to remain connected with them as they grew up and began to have children of their own. He also had a close and enduring relationship with his eldest sister, Ms Kerry-Ann Winmar, who had helped to raise Mr STW when he was young, alongside her own children.4

4. Over time Mr STW’s offending behaviours escalated and he committed a number of offences involving violence, such as grievous bodily harm and armed robbery. This offending resulted in Mr STW serving a number of lengthy periods in custody. He also spent periods of time in hospital as an involuntary patient due to drug-induced psychosis and risk of suicide.5

5. Mr STW’s family loved him very much and tried to support him in efforts to rehabilitate himself, but he was a strong-willed person, and he made his own decisions. Although he had periods of sobriety, he would eventually fall back into substance use, which then led him back into custody.

6. Towards the end of his last period of imprisonment, the State of Western Australia applied in the Supreme Court of Western Australia for a restriction order in respect of Mr STW under the High Risk Serious Offenders Act 2020 (WA) (the HRSO Act).

In summary, a restriction order is imposed on the basis it is considered necessary to ensure adequate protection of the community against an unacceptable risk that the offender will commit a further serious offence. It may be either a continuing detention order, which detains the offender indefinitely in custody, or a supervision order, which allows them to be released into the community but subject to stated 1 I refer to the deceased as Mr STW in this finding for cultural reasons at the request of Mr STW’s next of kin, Ms Winmar.

2 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025; Exhibit 2, Tab 24.

3 Exhibit 1, Tab 22.

4 T 194; Exhibit 1, Tab 22; Exhibit 2, Tab 24.

5 Exhibit 1, Tab 22.

[2026] WACOR 3 conditions that ensure they are supervised closely. The supervision is intended to reduce the risk of reoffending. Historically, these kinds of orders were only available in relation to serious sexual offenders, but under the more recent HRSO Act, an order can be sought for offenders who are at risk of committing serious offences involving violence.

7. On 28 January 2022, the State’s application was granted on an interim basis.

His Honour Chief Justice Quinlan was satisfied there were reasonable grounds for believing that the Court might find that Mr STW was a high risk offender, under the terms of the HRSO Act. His Honour determined it was desirable to make an interim post-sentence supervision order to ensure the adequate protection of the community.

Mr STW was subsequently released from custody on 13 February 2022 subject to the requirement he comply with the terms of the interim post-sentence supervision order (the interim supervision order) while living in the community.6

8. Mr STW was required to abide by extensive conditions under the interim supervision order, including a curfew, regular urinalysis, and electronic monitoring. He signed and accepted those conditions prior to being released. Mr STW moved into supported accommodation at The Beacon, which is run by The Salvation Army. He received support from The Beacon staff and some service providers connected with The Beacon while being supervised and monitored by Department of Justice staff and WA Police Force officers. Mr STW was still being supervised in the community and living at The Beacon at the time of his death.7

9. Mr STW’s final hearing was scheduled in the Supreme Court for 9 August 2022 but he attempted to take his own life by way of hanging the night before, so the hearing did not go ahead. He was found hanging in his room on the night of 8 August 2022 by The Beacon staff and was taken to hospital by ambulance. Despite intensive medical treatment, Mr STW died in hospital due to complications of hanging on 11 August 2022.

10. On 6 September 2022, the State Coroner formed the view that an inquest was desirable under the Coroners Act 1996 (WA) to examine the circumstances of Mr STW’s death, noting he was being monitored on the interim supervision order at the time of his death and this placed restrictions on his ability to live freely in the community. In particular, her Honour considered it was desirable to consider what support, if any, was being provided to Mr STW at the time he was being monitored in the community on the interim supervision order.8

11. Following the State Coroner’s direction, I held an inquest on 22 and 23 January 2025 in Perth on Whadjuk country. I understand from Mr STW’s eldest sister, Ms Kerry Winmar (Ms Winmar), that the inquest dates fell in the Nyungar season of Birak, which is the first summer. Ms Winmar attended the inquest hearing and spoke on behalf of herself and Mr STW’s extended family and community at the start and conclusion of the inquest.9 6 Exhibit 1, Tabs 17 – 18.

7 Exhibit 1, Tabs 17 – 18.

8 Sections 22(2) Coroners Act 1996 (WA).

9 T 2.

[2026] WACOR 3

12. During the inquest significant documentary evidence compiled as part of the WA Police and Department of Justice investigations into Mr STW’s death was tendered, and oral evidence was heard from some witnesses directly involved in Mr STW’s life on the interim supervision order, including: a. Department of Justice witnesses involved in supervising Mr STW on the interim supervision order, b. Police officers who were involved in monitoring Mr STW at the relevant time, c. Health experts who interviewed Mr STW as part of the HRSO Act Court process, d. a general practitioner who treated Mr STW prior to his death, and e. some support workers from the residential facility where Mr STW lived and who were involved with Mr STW on the day he was found hanging.

13. In addition, some witnesses were called to speak to the general policies and resourcing involved in seeking interim and final orders under the HRSO Act and monitoring of individuals on such orders, as well as what supports are available.

14. At the conclusion of the inquest, I invited submissions from the interested persons.

Written submissions were filed on behalf of Ms Winmar,10 the Department of Justice, WA Police11 and The Salvation Army.12 I have considered all of the submissions in reaching my findings.

BRIEF BACKGROUND

15. Mr STW was born in Bunbury and was the youngest of seven children, with a gap of 16 years between his eldest sibling, Ms Winmar, and Mr STW. The family moved to the Perth metropolitan area when Mr STW was still young. Mr STW recalled he had a happy early childhood. He described being raised in a Christian family with parents and siblings who worked hard and there were strict rules and boundaries in place regarding attending Church, using manners, completing chores and being respectful.

Mr STW later told a psychologist he felt loved by both his parents, but it was a busy household, with not only his siblings but also a number of cousins residing with the family. This meant that there was limited attention given to any individual child, although it is clear his siblings also provided him with support when his parents were too busy.13

16. There is some evidence before me to suggest Mr STW was exposed to violence in his childhood, but he was generally uncomfortable discussing matters that might paint his family in a negative light. He denied any exposure to alcohol misuse, substance abuse or overt violence in the family home when interviewed by a psychologist prior 10 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025.

11 Submissions filed on behalf of the Department of Justice and Western Australia Police dated 21 February 2025 and 10 March 2025.

12 Letter from counsel on behalf of The Salvation Army dated 12 December 2025.

13 Exhibit 1, Tab 21.

[2026] WACOR 3 to his death. Mr STW spoke highly of his parents and siblings. Both his parents and one older brother were deceased by the time Mr STW was placed on the interim supervision order, and he was deeply respectful of their memory. He explained he had run away from home because he rebelled against the strict rules of his upbringing. Mr STW’s parents were born in Badjaling community, and it was a very significant aspect of his family’s life. In the mid-1980’s, Mr STW’s family regained Badjaling Mission on a long-term peppercorn lease, which was a source of great pride for Mr STW. It marked his family’s enduring connection to country and has ensured the next generation has a place to heal.14

17. Mr STW’s sister described Mr STW as having come from a loving family who adored him. He was never alone growing up because his siblings and cousins were always around him. He was kind and always made people laugh. He was also strongwilled and took responsibility and ownership of the many decisions he made, both good and bad. His strength came from his faith and up until the time he passed away, Mr STW attended regular church services and also listened to gospel music for comfort and strength. Mr STW also loved football, barracking for the West Coast Eagles. He enjoyed hunting with his family and going on road trips through the heartland of Nyungar country. He especially loved visiting Kutter Kich (Wave Rock on Ballardong heritage trail) and Dwert Koorndie (Dog Rock in Albany).15

18. However, his substance use and related offending, played a negative role in his life, undermining the many good things. Mr STW’s medical history documented a history of self-harm and suicide attempts dating back to 1996, including attempts to harm himself while in prison as well as in the community. He made attempts by way of overdose, hanging and self-inflicted lacerations, amongst others. Mr STW had been diagnosed with antisocial personality disorder and substance use disorder (amphetamine and alcohol dependence) at various times. Ms Winmar believed her brother was psychologically impacted by prison and also acknowledged that his drug use took its toll on his physical and mental health.16

19. Mr STW had multiple emergency department presentations in the setting of methamphetamine intoxication, and he often required sedation/restraint. He had previously been on the methadone program and had a number of admissions to rehabilitation programs such as Fresh Start, but he did not manage to complete the programs and continued to abuse substances, to the detriment of his physical and mental health. Records suggest he had been asked to leave Fresh Start in 2021 due to extreme intoxication, threats of violence and threats of suicide.17

20. As noted above, his drug and alcohol use led to criminal offending. Mr STW had a long forensic history dating back to the 1990’s. He had spent accumulatively over 20 years of his life in prison when he died at the relatively young age of 46 years.

Much of his serious offending history involved armed robbery related offences perpetrated against both male and female victims. The nature of the offending was often impulsive and associated with his substance use.

14 Exhibit 1, Tab 21.

15 T 194; Exhibit 2, Tab 24.

16 Exhibit 2, Tab 24.

17 Exhibit 1, Tab 31; Exhibit 2, Tab 1, Tab 3 and Tab 13.

[2026] WACOR 3

21. Mr STW’s last presentation to hospital was in May 2017 when he was seen at Royal Perth Hospital in May 2017. He presented with low mood and suicidal ideation in the context of recent drug and alcohol use and following discharge from prison. During his psychiatric assessment he mentioned he had been injecting methamphetamine since his release as he was “not strong enough to stay away from it.”18 He was noted to have been residing at The Beacon since his release and seeing a counsellor at The Beacon on a regular basis at that time, but shortly before his presentation to hospital he had left The Beacon of his own accord and was homeless.

He was feeling frustrated with himself for not being able to keep away from drugs as he had been trying hard to do the right thing. He was recommended for a voluntary admission for containment of risk to himself at that time and I understand his situational crisis eventually resolved.19

22. On 29 March 2021 he was released on parole and went to participate in the Fresh Start program in Northam. He then relapsed into drug use and left the programme.

He consequently breached parole and was sent back into custody.20

23. Mr STW returned to prison for the last time on 21 June 2021, having been out on parole for only three months. He told a prison officer during an admission risk assessment that he had feelings of shame and disappointment at that time. He mentioned he had put a belt around his neck prior to coming into prison, which led to him being initially placed on high At Risk Management System status. However, a few days later told a nurse he was feeling “disappointed but philosophical”21 and he later denied any further thoughts of self-harm, so his risk status was reduced.

Mr STW spent most of his last period of incarceration in Acacia Prison until he was released on 13 February 2022 on the interim supervision order. He had been in custody 7 months and 24 days at that time.22

TERMS OF THE INTERIM SUPERVISION ORDER

24. As noted above, Mr STW was subject to an Interim Post Sentence Supervision Order, or interim supervision order, at the time of his death. The interim supervision order had been imposed by the Chief Justice on 28 January 2022.

25. Leading up to the court hearing, Department of Justice staff had met with Mr STW in prison and discussed some of his personal details and the likely terms of the interim supervision order, noting he had previously been released on parole but had not been on an order under the HRSO Act before.

26. His Honour imposed 35 standard conditions for Mr STW’s supervision, including regular reporting to Community Corrections and to officers at the WA Police Sex Offender Management Squad/Serious Offender Management Squad (SOMS) and 18 Exhibit 1, Tab 31, p. 3.

19 Exhibit 1, Tab 31.

20 Exhibit 2, Tab 3 and Tab 13.

21 Exhibit 2, Tab 13, p. 5.

22 Exhibit 2, Tab 13.

[2026] WACOR 3 restrictions against consuming drugs and alcohol and ensuring his exposure to substances was limited, amongst other things. A condition of the interim supervision order was that Mr STW reside at The Beacon in Northbridge and spend each night there, with a curfew in place, unless a different address was approved by his Community Corrections Officer.23

MANAGEMENT ON THE INTERIM SUPERVISION ORDER

27. At the time of his death, Mr STW was still required to live at The Beacon supported accommodation in Northbridge. The Beacon is managed by The Salvation Army and provides accommodation and other services to adults who are experiencing homelessness. Mr STW had experienced homelessness in the past when released from prison and he required stable accommodation as part of his interim supervision order. The Beacon was considered a suitable housing option, at least for the initial stage after his release. I understand it is possible Mr STW could have arranged his own accommodation in due course, but that would obviously take time and would need to be approved.

28. Under Mr STW’s reporting obligations, he was required to meet with supervisors from the Department’s Community Offender Monitoring Unit (COMU) and he was also required to meet with police officers from the SOMS for monitoring of his compliance while on his interim supervision order.24 I note Mr STW was not convicted of sexual offences. This was the original name of the squad that monitors offenders subject to final and interim protection orders, originating at a time when only offenders convicted of sexual offences could be subject to such an order. Since that time, due to a change in applicable legislation, monitoring by SOMS has expanded to include other kinds of offenders convicted of serious violent offences, which is how Mr STW came to fall within its scope.

29. Mr STW was initially required to attend weekly appointments where his situation and compliance with his interim supervision order requirements were reviewed.

Notes from the appointments indicate that Mr STW intermittently expressed dissatisfaction or frustration with how the interim supervision order imposed restrictions on his lifestyle choices. He often saw the same supervisors and police officers, so it appears they came to know him reasonably well.

30. Ms Trudy Hill (Ms Hill) was working as a Senior Community Corrections Officer (SCCO) at the COMU in early 2022 when Mr STW was first released from prison on the interim supervision order in February 2022. One of her roles as a SCCO was to supervise and manage offenders under the HRSO Act. Ms Hill was assigned as Mr STW’s first case manager. Ms Hill explained that her role was initially to ensure that Mr STW had a full and comprehensive understanding of the purpose and intent of the interim supervision order and the expectations around his compliance with its conditions. Ms Hill met with Mr STW weekly for the first month to monitor how he was reintegrating back into the community and to identify any supports he needed to 23 Exhibit 1, Tab 2 ant Tab 17.

24 T 35; Exhibit 1, Tab 7.

[2026] WACOR 3 comply with the interim supervision order and ensure he was put in contact with the necessary services and agencies.25

31. Ms Cassie McNally (Ms McNally) was the COMU Team Leader for Ms Hill from 3 February to 3 March 2022, when Mr STW was triaged and placed on the interim supervision order. She then went on long service leave and Ms Hill took over her role. When Ms McNally returned from long service leave in June 2022 another SCCO, Ms Jenny Sullivan (Ms Sullivan), was Mr STW’s SCCO and Ms McNally was her line manager other than for a brief period. As the Team Leader, Ms McNally never met Mr STW herself, but she was involved in meetings where Mr STW’s progress on the interim supervision order was discussed and she also had direct discussions with external providers in relation to issues affecting Mr STW.

32. As Mr STW’s first allocated case manager, Ms Hill first met with Mr STW at Acacia Prison on 10 February 2022, a few days prior to his release. They discussed some of his personal details, including his physical and mental health. Mr STW denied being on any medication and he did not raise any issues in relation to his mental health at that time. This included a discussion about whether he was feeling apprehensive or anxious about his release and the interim supervision order, noting Mr STW had previously experienced some supervision in the community on parole and had ultimately been breached on his parole and returned to prison. Mr STW told Ms Hill the parole breach had been a ‘wakeup call’ and he was hoping to use this experience as a motivator for the future.26

33. Ms Hill gave evidence that although Mr STW’s 35 conditions on the interim supervision order, sounds like a lot, it was at the lower end of what she would expect to see for a person on a HRSO Act order. Nevertheless, it’s clear she spent some time explaining the nature of some of the conditions, such as the need to not attend any licensed premises, to find ways to avoid returning to substance use and to comply with his curfew, as these were obvious areas for potential non-compliance. Mr STW told Ms Hill he intended to keep a positive mindset and try to view the interim supervision order as an assistance to keep him on track, rather than a hindrance.27

34. However, it seems that fairly quickly after his release Mr STW’s positive mindset diminished and he quickly became frustrated with the restrictions. At their first meeting on 14 February 2022, the day after his release from prison, Ms Hill noted Mr STW presented as agitated and frustrated as he felt overwhelmed by all of the appointments he needed to attend. He said he just wanted a little time to ‘settle’ first.

He also resented the implication from the interim supervision order that he was a risk to the community. Mr STW disclosed to Ms Hill that he was feeling depressed and suicidal, although he denied any active intent or plan to harm himself or suicide.

Mr STW told Ms Hill he would arrange to see a doctor through The Beacon, although he didn’t want to take medication.28 25 T 70 - 71; Exhibit 2, Tab 17.

26 T 72 – 73; Exhibit 2, Tab 17 and Tab 17.1.

27 T 72 – 73; Exhibit 2, Tab 17 and Tab 17.1.

28 T 73; Exhibit 2, Tab 17.

[2026] WACOR 3

35. Ms Hill was sufficiently concerned about Mr STW’s disclosure that she went to The Beacon and conducted a home visit with him later that afternoon. Mr STW told Ms Hill he was now feeling more settled, and this was confirmed by his support worker at The Beacon. Ms Hill was reassured that Mr STW appeared less overwhelmed and more settled in his environment, so she did not take any further action that evening.29

36. The following day, Ms Hill emailed Mr STW’s case worker at his support agency, ReSet, and received confirmation that Mr STW still seemed settled. She then commenced a referral for Mr STW to the Department’s forensic psychology team, which is a standard process for anybody who is made subject to an interim supervision order. Ms Hill was aware there was a significant waitlist for the psychology service, known as the Forensic Psychological Intervention Team (FPIT) at the time, so she wasn’t expecting him to be seen immediately.30

37. Ms Hill gave evidence she understood the psychological intervention from the FPIT would focus on Mr STW’s risk of recidivism and criminogenic risk factors, so the referral was not directed towards general psychological intervention arising from his disclosure the previous day. Ms Hill said she thought Mr STW would have benefited from more general psychological intervention, but it seems that was more likely to come through the services available to him at The Beacon than through his Community Corrections management. In the end, Mr STW was never reviewed by the FPIT. I will return to this topic later.31

38. On 17 February 2022, Ms Hill reviewed a Risk to Self – Self Harm Alert for Mr STW recorded on the system. She recommended the alert remain active due to his recent disclosure of suicidal ideation.32

39. Ms Hill met with Mr STW again on 18 February 2022. They had a long discussion, and he indicated he was feeling settled at The Beacon and he seemed more relaxed.

They discussed his plan to see a GP regarding his mental health. Mr STW said he was feeling a lot better and didn’t seem keen to progress it. He suggested that he thought the police at SOMS did not think he would succeed on the interim supervision order, but he remained positive he could remain off drugs and alcohol and said he would try to use the conditions of the interim supervision order as a positive framework to stay out of prison.33

40. However, once again it seems that his positive mindset deteriorated quickly due to the frustrations of trying to comply with the various conditions. For example, Mr STW met up with his oldest sister, Ms Winmar, and she took him to see his parents and brother, which had been a very positive and enjoyable experience.

However, as part of the car journey, they inadvertently entered part of the Northbridge exclusion zone, which meant Mr STW had not complied with a condition of his interim supervision order. Ms Hill discussed this breach with 29 T 74 – 75; Exhibit 2, Tab 17 and Tab 17.2 to 17.3.

30 T 77 – 79; Exhibit 2, Tab 17.

31 T 77 – 79; Exhibit 2, Tab 17.

32 Exhibit 2, Tab 17.

33 Exhibit 2, Tab 17, Tab 17.6 and Tab 17.9.

[2026] WACOR 3 Mr STW on 21 February 2022 and indicated she was recommending only a verbal warning, but the final decision had not yet been reached. He was involved in similar breaches of the exclusion zone over the following days, although all were similarly minor in nature.34

41. It seems clear that at this stage Mr STW was looking for ways to try to reduce the onerous nature of the conditions and progress the supervision process, in the hope that when his next court date arrived there was a prospect he could possibly have the interim supervision order lifted. On 28 February 2022, Mr STW met with Ms Hill again and he queried when his psychological counselling might commence. Mr STW advised he would like to engage in this prior to his next court appearance and also indicated he wanted his court hearing to be listed earlier. Ms Hill explained his court date would not be brought forward and Mr STW expressed some annoyance at the drawn out court process, once again emphasising he did not think he was a risk to the community.35 Ms Hill then ceased to be Mr STW’s case manager, as she began acting in the Team Leader role. She continued to have oversight of his case in the Team Leader context until June 2022.

42. Mr STW saw General Practitioner Registrar Dr Sean Hodgkinson (Dr Hodgkinson) at Homeless Healthcare on 16 March 2022 via a telehealth consultation. Mr STW had been out of prison for about one month at that time. Mr STW “stated he was feeling overwhelmed due to the restrictive Court order which was in place.”36 Mr STW was also feeling a bit anxious and struggling with sleep disruption, although he remained positive about his future, noting he was training for his crane licence at the time. On questioning, there was no indication of suicidality. It appeared to Dr Hodgkinson that Mr STW was suffering from an adjustment disorder with anxiety. Dr Hodgkinson explained at the inquest that an adjustment disorder “is functionally often very similar to depression in terms of how if manifests, but it’s specific in that it’s a shorter timeframe and it’s directly attributable to a discrete event.”37 In Mr STW’s case, Dr Hodgkinson felt it was his response to the change in his circumstances from leaving prison to release on a post-prison order. Dr Hodgkinson gave evidence an adjustment disorder is typically managed through therapy, rather than medication.38

43. Dr Hodgkinson considered Mr STW was managing reasonably well but it was clear he was “glad to be able to talk it all out.” 39 They discussed the option of Mr STW seeing a private therapist at The Beacon for some ongoing support, but Mr STW refused as he felt he was too busy. He also declined the option to reduce some of his personal commitments until his Court ordered requirements became lighter. When Dr Hodgkinson explained that he had limited capacity to influence Court orders, Mr STW became frustrated and abruptly ended the consultation.40 34 Exhibit 2, Tab 17, Tab 17.6 and Tab 17.9.

35 T 81; Exhibit 2, Tab 17.13.

36 Exhibit 2, Tab 19, p.2.

37 T 18.

38 T 18 – 19.

39 Exhibit 2, Tab 19, p.2.

40 T 16; Exhibit 2, Tab 19.

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44. In her capacity as Team Leader, Ms Hill continued to be informed of Mr STW’s progress on the interim supervision order. She was informed that it was identified in a case review that Mr STW had become reluctant to engage in psychological intervention, which was a shift from his previous attitude expressed when Ms Hill was his Senior CCO. Ms Hill felt it was possible he had begun to understand that engaging in psychological intervention wouldn’t help him avoid having a final order imposed. Ms Hill had previously explored with Mr STW the possibility of a GP initiating a Mental Health Care Plan, which would have allowed him a number of counselling sessions. It does not appear he had followed this up when he had seen Dr Hodgkinson. Ms Hill made a note that his change in attitude to engaging in psychological intervention should be explored with Mr STW further.41

45. Ms Sullivan was Mr STW’s Senior CCO at that time, having taken over from Ms Hill in March 2022. Other than for a brief period when she was on leave, Ms Sullivan remained Mr STW’s case manager thereafter. Ms Sullivan gave evidence at the inquest that she remembered Mr STW very well, primarily because of his sudden death while she was his supervisor. Ms Sullivan remembered him as a very deep thinker and commented that he struck her “as someone who had a lot going on internally, but was very calm … on the surface.”42 Nevertheless, Ms Sullivan had felt she had established a reasonably good rapport with Mr STW in the months she was interacting with him. Ms Sullivan gave evidence that for the majority of the time she supervised him she believed he was doing really well, but unfortunately when things started to go wrong at the end it became known that he had not been doing so well and he had been “internalising everything and not disclosing those struggles he was having.”43

46. Ms Sullivan met with Mr STW on 22 March 2022, and they discussed changes to his curfew to allow him to attend training for work. He was given a verbal warning for entering an exclusion zone, which had occurred during a driving lesson. He became understandably frustrated, expressing his view the interim supervision order was ‘holding him back’. Mr STW had mentioned his appointment with Dr Hodgkinson, and it was in this context that Mr STW mentioned seeing a psychologist, as the doctor had recommended, he engage in counselling for his anxiety. Mr STW expressed reluctance to see a psychologist as he didn’t want to spend time talking about his past offending, noting he believed it all stemmed from drug and alcohol use. Mr STW commented “you shouldn’t condemn a person for their entire life based on their past.”44

47. Ms Sullivan reminded Mr STW at the time that he was only on an interim supervision order, and he was making good progress, so what would happen in the future was still under review. She gave evidence at the inquest that she also understood he found the psychological and psychiatric interviews he had to engage in for the purpose of the Court proceedings quite triggering as he was required to talk about his past offending behaviour. He found it difficult to talk about his past, so she

41 T 80 – 82, 88.

42 T 123.

43 T 124.

44 Exhibit 2, Tab 12, p. 302.

[2026] WACOR 3 understood this may have put him off engaging in other counselling that might have been more therapeutic.45

48. Ms Sullivan offered to refer Mr STW to substance abuse counselling in April 2022 after they had discussed his struggles to adapt to life without drugs or alcohol. He had always used substances to suppress uncomfortable emotions, and he told her he was particularly struggling with alcohol cravings. Mr STW declined a referral, indicating to Ms Sullivan he felt he knew his triggers and what to do, he just needed to apply it. Ms Sullivan gave evidence she felt that since he had just taken up full time employment and his urinalysis results at that stage were negative, it was reasonable to respect his decision at that time.46

49. Mr STW had secured work in the construction industry with a company called Skill Force. He was also taking driving lessons to help him obtain his driver’s licence, which would likely open up further job opportunities for him. He was seeing CCO staff about once a week and the police at SOMS now once a fortnight, as well as The Beacon staff daily. He also had contact with support organisations THRIVE and Wungening Aboriginal Corporation (who provide services through the ReSet program). In addition, records indicate he was regularly attending church and seeing his family. He sought an extension of his curfew to allow him to go out after work for a walk/meal or to see his family. He also asked for permission in advance to go with his sister to the Crown complex over Easter. Mr STW spoke to Ms Sullivan on 12 April 2022 about his plans to start a petition and have everybody involved in his life sign it, in order to convince the Court, he was not a risk, as well as try to get the court date brought forward once again. Ms Sullivan tried to manage his expectations, at least in relation to changing the court date.47

50. On 29 June 2022, it was noted Mr STW had a new contact on his mobile phone. The contact was a woman who also resided at The Beacon, and it seems she was asking him for money. It was indicated this would be closely monitored. Mr STW apparently had commenced a relationship with this woman, with Ms Sullivan only becoming aware of the relationship when she was reviewing his phone a couple of weeks later. It later became apparent this new relationship coincided with his relapse into drug use.48

51. Mr STW saw Detective Senior Constable Andrew McSweeney, who was attached to the WA Police SOMS Team at the time, for another review on 11 July 2022.

Mr STW was recorded as having arrived early and was in his work gear. He reported he was working on a construction site in the city and was enjoying the work. He had been given good feedback by his boss, including being told it was possible he would be kept on to work at a new site in December. Mr STW was still living at The Beacon and indicated he liked its proximity to his work, but he was also keen to try to get a place of his own in the future. He was attending his required supervision sessions and said he believed he had changed for the better but felt he would have done so without being on the interim supervision order. The next court date was

45 T 125.

46 T 124; Exhibit 2, Tab 11, p. 343.

47 T 124 – 125; Exhibit 2, Tab 11, p. 343.

48 T 126.

[2026] WACOR 3 scheduled for 9 August 2022 and Mr STW mentioned that he had family in Victoria, so if he was put on a full-time supervision order he hoped it would allow him to transfer interstate.

52. Despite the positive meeting on 11 July 2022, concerns were raised with the SOMS team two days later about possible drug use and some videos of a sexual nature on Mr STW’s phone. He subsequently failed a random urinalysis that day, with his sample testing positive for methamphetamine. He was charged on 19 July 2022 with using a prohibited drug and contravening a requirement of a supervision order.

Mr STW appeared in the Perth Magistrates Court on 20 July 2022, pleaded guilty to the charges and was fined $2000. Mr STW later admitted he had been drinking and using illicit drugs on and off on other occasions during the interim supervision order.49

53. Ms Sullivan followed up Mr STW’s referral for psychological counselling with the FPIT after these events on 20 July 2022. She received a response indicating that the FPIT were at capacity, and it was suggested that he engage with drug and alcohol counselling or mental health services instead. At the inquest Ms Sullivan could not recall this specific exchange, but she gave evidence it did not surprise her as she was aware at the time there were staffing issues, so it was quite a common response.

Ms Sullivan indicated she had followed it up because it had been five months since the referral and Mr STW was still waitlisted. Ms Sullivan commented that she had not thought he was in high need of counselling until that time, but when he had made those disclosures, she had followed it up. In hindsight, she wondered if psychological intervention from the start of his interim supervision order might have influenced a different outcome. However, Ms Sullivan also understood the FPIT counselling would have focussed on his criminogenic needs and offending behaviour, so she agreed that he might have benefited more from some private counselling to deal with his feelings of suicidal ideation.50

54. Ms Sullivan observed that Mr STW had been working full-time until then, which had been a hindrance to engaging in some of these services. He had also generally expressed a reluctance to engage. His attitude seemed to change around this time, perhaps as the possible consequences of his breach started to concern him. Mr STW met Ms Sullivan for a case management meeting on 20 July 2022 and he told her he was going to resign from his job and see a doctor to seek help for depression and anxiety so he can “stop feeling suicidal.”51 He also told Ms Sullivan he had ended the new relationship with Ms Tahlie Barrett (Ms Barrett) as he had realised she had her own problems and he didn’t think the relationship was what he needed at that time.52

55. Mr STW went to the Derbarl Yerrigan Health Service for medical review that same day. He requested a full check over, noting that he had been released from prison in February 2022 and was recently feeling a bit off, finding it hard being on restrictive conditions and was feeling anxious and depressed. He said he usually used amphetamines to cope, but this was something that was not allowed while he was on 49 Exhibit 2, Tab 11.

50 T 126 – 127, 132; Exhibit 1, Tab 19 and Tab 20; Exhibit 2, Tab 11, p. 492 - 500.

51 Exhibit 2, Tab 11, p. 500.

52 T 126 – 127, 132; Exhibit 1, Tab 19 and Tab 20; Exhibit 2, Tab 11, p. 492 - 500.

[2026] WACOR 3 the interim supervision order, so he wanted to be prescribed medications to help him cope. Mr STW admitted experiencing some suicidal ideation and said he had engaged in some planning, specifically the thought of buying some ropes. However, he also said he had good social supports, including at the accommodation where he was staying and from Wungening and its ReSet program. Mr STW was given a six week prescription for the SSRI antidepressant escitalopram, with a plan that he return in six weeks for review, or sooner if required. He was given advice around avoiding unhealthy and risk-taking behaviours and the supports he could access and encouraged to have some blood tests and other investigations to assess his physical health in addition to his mental state.53

56. Mr STW’s partner, Ms Barrett, rang Ms Sullivan later that day and suggested Mr STW had been drinking. In response, Ms Sullivan contacted Mr STW and asked him to complete urinalysis. He responded angrily and said he felt the staff were ‘picking on’ him, although he then calmed down and apologised to Ms Sullivan and complied with the request. He spoke to Ms Sullivan prior to doing the urinalysis and blamed the new relationship for his relapse, although he also said he felt staying at The Beacon was “a bad environment for him.” He seemed to feel let down by the system and as if he had been “set up to fail by the Department.”54

57. Ms Sullivan took the opportunity to speak to him about his mental health. Mr STW said he had been given a prescription for antidepressants that morning but hadn’t filled it yet. He said he felt like he needed to be in a ‘psych ward’ and mentioned he had gone to a service station to buy a rope to hang himself. Ms Sullivan reminded Mr STW that even once he began taking the antidepressant medication it might take weeks to take effect. She asked if he would be okay overnight and suggested he might want to go to Royal Perth Hospital Emergency Department to address his mental health concerns. He declined and said he would be okay once he had a sleep, noting he hadn’t been eating or sleeping lately (which was likely related to the recent amphetamine use). Sadly, Mr STW also spoke of his feeling that he didn’t know how to live in the community anymore and felt like he could “survive easier in custody.”55 He then said he just needed to go home and rest. Ms Sullivan reminded him that if he changed his mind about going to hospital, he could speak to a Duty Manager who would arrange for this to happen. She also asked him to call her in the morning so she would know he was alright. As he left the building, he yelled out, “I feel like I’m gonna kill someone or kill myself.”56

58. Ms Sullivan was asked at the inquest about her recollection of her conversation with Mr STW that day. She recalled him making the statement about possibly killing someone else or himself when he left the interview room and she recalled that she looked him in the eye and said, “Please don’t do that … I don’t want to come to work one day and get that phone call.”57 At the time she thought he looked surprised to think that she might care.

53 Exhibit 2, Tab 1.

54 Exhibit 2, Tab 11, p. 506.

55 Exhibit 2, Tab 11, p. 506.

56 Exhibit 2, Tab 11, p. 506.

57 T 127.

[2026] WACOR 3

59. Ms Sullivan rang The Beacon staff after Mr STW left to ‘give them a heads up’ about Mr STW’s fragile mental health. A staff member at The Beacon told Ms Sullivan she had spoken to him half an hour ago and he had appeared okay, but confirmed the staff would conduct a couple of welfare checks on him overnight.

Ms Sullivan also rang Mr STW and spoke to him to check on his welfare personally.

He stated he was resting and feeling okay. Ms Sullivan reminded him to reach out for help if things got worse during the night and he agreed.58

60. Ms Sullivan spoke to Mr STW’s case manager at The Beacon the following day to arrange a meeting to discuss potential rehabilitation options for him. Mr STW then visited Ms Sullivan. She observed he was looking better than the previous day. He indicated he would be collecting his antidepressants that day and hoped they would help, although he was already feeling better after a good sleep and some food. His work colleagues were encouraging him to come back to work, but he had decided he would try to go to Bridge House for substance use rehabilitation instead, which Ms Sullivan encouraged. They discussed his most recent positive urinalysis, which had occurred before his recent court appearance although the results had come in after. He indicated he would work hard to avoid any further positive test results and discussed a referral to financial counselling as Mr STW admitted he wasn’t good at managing his money, other than to spend it on drugs.59

61. Following a case review conducted between Ms Sullivan and her Team Leader, Ms McNally, they agreed Mr STW should remain on high supervision. It was noted he had been having some issues with drug and alcohol use and his mental health had deteriorated, but it was felt that now he had ceased employment and ended his new relationship he appeared to have somewhat stabilised. It was noted that he was still waitlisted for psychological counselling. Mr STW was working towards entry into a rehabilitation programme and Ms Sullivan was planning to meet with Mr STW and his case manager at The Beacon on 26 July 2022 to discuss his options.60

62. The meeting went ahead as planned on that date and the process for getting Mr STW into residential drug and alcohol rehabilitation with Bridge House was discussed, with a note that it could take up to a month for a place to become available. It was also agreed that The Beacon staff would help with the financial counsellor referral.

Ms Sullivan followed up the Bridge House referral on 29 July 2022, but no admission date was set.61

63. Mr STW was seen at the Homeless Healthcare service a few days’ later, on 1 August 2022, for review of his antidepressant escitalopram that had been commenced by a doctor at Derbarl Yerrigan Health Service. Dr Hodgkinson, who had previously spoken to Mr STW once in March 2022, saw Mr STW again for this appointment. This was the first time they had met face to face. Dr Hodgkinson recalled Mr STW was quite reserved but otherwise pleasant and easy to interact with during the consultation.62 When Dr Hodgkinson had first met Mr STW, his 58 T 128; Exhibit 2, Tab 11, p. 507 - 508.

59 Exhibit 2, Tab 11, p. 511.

60 Exhibit 2, Tab 11, p. 514 – 515, 523.

61 Exhibit 2, Tab 11, p. 514 – 515, 523.

62 T 11; Exhibit 1 Tab 24; Exhibit 2, Tab 19.

[2026] WACOR 3 preliminary diagnosis had been that Mr STW was suffering from an adjustment disorder. Now in August, he considered it had shifted to a diagnosis of major depressive disorder given the duration of symptoms. Mr STW reported to Dr Hodgkinson that he was going well on the antidepressant medication and felt that it helped with his depression. He indicated he had no suicidal thoughts and mentioned his positive plans to commence substance abuse rehabilitation. On the basis of Mr STW’s positive report, Dr Hodgkinson provided him with a continuation of his prescription for escitalopram. Mr STW also asked for time off work to accommodate his rehabilitation plan, so Dr Hodgkinson gave him a medical certificate to provide to Centrelink for the period 1 August 2022 to 1 October 2022.63

64. Mr STW was given a written warning letter on 2 August 2022 in relation to his positive urinalysis results that had predated his recent court appearance and for deleting his phone messages. Mr STW mentioned he had seen Dr Hodgkinson the day before and he had another prescription for his antidepressants and was feeling well. He also had a medical certificate for Centrelink and had done his tax and was expecting a healthy tax return. He was due to see his lawyer the next day in relation to his upcoming Court appearance and had letters of support from his employers. He was still looking forward to entering rehabilitation and mentioned he had a new partner who lived in the country and was a steadier influence than Ms Barrett.

Ms Winmar had offered to buy him a car when he got his driver’s licence, and he was hoping to continue lessons while at Bridge House. Overall, he appeared to be feeling positive and future focussed.64

65. A case management meeting between Ms Sullivan and Ms McNally a couple of days later recorded he was applying for residential drug and alcohol rehabilitation, and he had his court hearing in a few days’ time. It was noted he was in a new relationship and that this should be monitored, given his previous relationship had caused him some issues and it was possible Mr STW was not being entirely truthful about the new person’s background.65

66. Ms Winmar recalled that nearing up to Mr STW’s death her brother had told her not to worry about his mental health. Nevertheless, when a few days passed and she did not hear from him, she was concerned as it was very unusual for him not to be in regular contact. Ms Winmar was aware that being on the interim supervision order impacted upon Mr STW’s mental health and she observed that the restrictive conditions were “getting him down.”66 For example, Ms Winmar recalled one occasion when they took the wrong route and he received a notification that he was in breach. Although he told her he would sort it out, it was clear to her from the look on his face that Mr STW was worried. He told her afterwards that it made him feel bad as he didn’t like having the electronic monitoring device on his ankle and knowing that people were monitoring his movements all the time.67 63 T 19; Exhibit 1, Tab 24; Exhibit 2, Tab 19.

64 Exhibit 2, Tab 11, p. 520.

65 Exhibit 2, Tab 11, p. 533 – 534.

66 Exhibit 2, Tab 24 [22].

67 T 195; Exhibit 2, Tab 24.

[2026] WACOR 3

67. Ms Winmar also felt that the terms of Mr STW’s interim supervision order meant he could not go to Badjaling Mission, go hunting with his family or attend funerals, due to the need to have him home in time for his curfew. Ms Winmar stated that she tried to ask Corrective Services to be permitted to take her brother home to Badjaling Mission, as “[g]oing back to country is healing for Nyungars,”68 but it had not been approved prior to his death, which she believes affected him. Ms Winmar did her best to support her brother while he remained in Perth, including arranging for him to have a phone and iPad and picking him up most days so they could spend time together and she could take him to visit people, but it was often cumbersome to drive on routes that did not breach the terms of his interim supervision order and he felt that it limited his ability to spend time with his children and grandchildren, which was understandably very important to him.69

68. Another relative of Mr STW, Mr Arnold Yarran (Mr Yarran), also provided some information about Mr STW for the Court’s benefit. Mr Yarran described Mr STW as someone who “liked talking, taking and giving advice. If he saw you doing something wrong, he’d pull you up and tell you.”70 When he made mistakes himself, he would fix them and work forward rather than looking backward. Mr Yarran had contact with Mr STW in the last few months of his life and he believed that Mr STW had been in the best place Mr Yarran had seen him in many years. He was trying hard to live a good life and Mr Yarran could see that he was looking after himself, working hard and had a spring in his step. However, Mr Yarran also understood that Mr STW’s inability to engage with important cultural practices like hunting and attending funerals would have impacted upon Mr STW but he believed it might have been hard for him to talk about these things with non-Aboriginal people. As a Nyungar man, Mr Yarran was able to explain in particular the barriers Mr STW would likely have felt speaking to women, such as his CCO’s, because of cultural barriers, as well as the lack of trust many Aboriginal men feel towards government services due to historical trauma.71

COMMUNITY SUPERVISION ASSESSMENT

69. I note one of Mr STW’s Senior CCO’s referred in his Initial Case Review to his Honour Chief Justice Quinlan’s comment in his reasons that Mr STW’s most serious recent offending revealed “a pattern of opportunistic, and frankly ham-fisted, armed robberies, committed in the context of his use of drugs and alcohol.”72 I understand Mr STW was generally considered to be a high risk of reoffending in a similar way if he relapsed into drug and alcohol use. Within Mr STW’s records was a list of his high-risk factors in that context, and how each of his risks were to be managed, which are reproduced below.

68 Exhibit 2, Tab 24 [26].

69 T 196; Exhibit 2, Tab 24.

70 Exhibit 2, Tab 22 [8].

71 Exhibit 2, Tab 22.

72 Exhibit 1, Tab 18 – The State of WA v Winmar [2022] WASC 27 [15]; Exhibit 2, Tab 11, p. 288.

[2026] WACOR 3 Minutes of Risk Management Meeting73 High risk factors: Managed via: Propensity towards violence and Weekly supervision with SCCO anti-social attitudes. Impulsivity and Home visits poor problem solving and poor Curfew coping. Psychological counselling Global Positioning System (GPS) monitoring Substance misuse including alcohol As above plus: Urinalysis – weekly/twice weekly SOMS – breath testing Substance Abuse Counselling Lack of personal support, few pro- As above plus: social supports Engagement with Reset

70. The minutes from the Risk Management Meetings from February to August 2022 show that Mr STW was receiving intensive monitoring in relation to his identified risk factors. It was noted that he was frustrated at the lengthy court process but appeared to generally be coping reasonably well on the interim supervision order.

71. Mr STW was due to appear again in the Supreme Court on 9 August 2022. At that time, I understand Mr STW could have been placed on a Final Supervision Order with conditions, or no further order might have been made, in which case I understand he would have been free to live in the community. Alternatively, he could have been placed on a Continuing Detention Order (CDO), which would have required Mr STW to return to prison for an indefinite period. The decision would involve review by the presiding Supreme Court Judge of how Mr STW had gone on the interim supervision order, as well as consideration of the expert opinions a forensic psychologist and forensic psychiatrist who had reviewed Mr STW as part of the process.

72. His primary Senior CCO for much of the term of his interim supervision order, Ms Sullivan, observed that Mr STW may have been on more conditions than was necessary because it was an interim supervision order and there were no expert assessments at that stage available to identify his risk factors. Once the court process had concluded, Ms Sullivan had anticipated they would have been tailoring the conditions more to Mr STW’s needs. Ms Sullivan had not thought there was any possibility Mr STW would be returning to prison after his next court appearance as the number of contraventions and the seriousness of his contraventions was, in her experience, relatively low. Ms Sullivan observed that for a person like Mr STW a positive urinalysis result is really to be expected. She also observed that anyone on an interim supervision order with that many conditions will receive contraventions.

Ms Sullivan commented that until his unravelling and relapsing into drug use, she had actually thought there was a chance Mr STW might not get an order at all because he had been so compliant. Ms Sullivan gave evidence she had no inkling that 73 Exhibit 2. Tab 9.

[2026] WACOR 3 Mr STW thought that a return to prison was a possibility. She recalled she had told him on multiple occasions that he was doing really well and that he needed to focus on the good things he was doing. However, it seems he remained concerned.74

73. Ms Hill, Mr STW’s first Senior CCO, also agreed in questioning that people like Mr STW and other persons subject to these orders can find the nuances of the conditions difficult to understand, leading to non-intentional breaches. For example, Mr STW breached the Northbridge exclusion zone numerous times due to inadvertently driving through it, and he also breached the prohibition against entering licensed premises more than once when he went to eat in a cafe or restaurant that had a liquor licence.75 The verbal warnings were intended to educate Mr STW and assist him not to breach the condition again, as the consequences of repeated breaches might escalate. Nevertheless, Ms Hill accepted it was inevitable that with so many conditions some would be breached, whether deliberately or inadvertently. However, from Mr STW’s perspective, the breaches put him at risk of going back to prison and that seems to have become his focus at the end.

74. The experts consulted as part of the assessment were Consultant Forensic Psychologist, Ms Julie Hasson (Ms Hasson), and Forensic Consultant Psychiatrist Dr Gosia Wojnarowska (Dr Wojnarowska).

75. In her report dated 7 July 20222 prepared by Ms Hasson for the Presiding Judge for the Supreme Court hearing, Ms Hasson included a comprehensive review of Mr STW’s life history, offences, and interactions with the Department of Justice, followed by a diagnostic assessment, risk assessment and recommendations.

Extracted from the Summary and Recommendations section of the report, Ms Hasson noted that:76 Whilst it is acknowledged that Mr STW had made some treatment gains through his participation in programs and also through his experience in the community to date, a number of treatment needs remain outstanding and there is a need for consolidation and expansion of existing skills through engagement in further counselling, treatment, programs, supervision, support and monitoring and the provision of structure and accountability. His new skills have yet to be tested over any significant period of time free in the community or in the face of significant stressors. Based on the current assessment it is the author’s opinion that Mr STW presents as a high risk of serious reoffending if not subject to a period of supervision and monitoring given his history of relapsing into substance abuse, interpersonal aggression and violent behaviour.

76. Ms Hasson expressed the opinion in her report that Mr STW would benefit from further interventions “to assist him to develop more robust emotional management and coping skills.”77 She considered his substance use was one of his most significant risk factors, so she recommended he required ongoing counselling to help

74 T 128 – 129, 134.

75 T 98 – 99.

76 Exhibit 1, Tab 21 [110].

77 Exhibit 1, Tab 21 [111].

[2026] WACOR 3 him develop strategies to keep him abstinent. I note Ms Hasson considered this was important in the context of some history of intimate partner violence, as well as his more recent violent armed robbery offences.78

77. Prior to the inquest, Ms Hasson advised the Court that she considered her original report to be comprehensive in terms of the issues facing Mr STW. She confirmed her understanding that Mr STW was not receiving any psychological support at the time he was on the interim supervision order, which she understood was common practice. Ms Hasson expressed her opinion that “all offenders being considered under the HRSO Act legislation should be offered some form of psychological counselling/support by Departmental staff due to the stressful nature of the process.

The process is daunting, frustrating and at times overwhelming.”79 Specifically in relation to Mr STW, Ms Hasson expressed her belief Mr STW “should have had access to a departmental psychologist to process his anger, frustration, fear, resentment, hostility and other thoughts and feelings associated with his involvement in the HRSO Act process.”80

78. Ms Hasson gave evidence she had spoken to Mr STW during a three hour interview on 28 June 2022, as well as reviewing various materials and speaking to Ms Sullivan, prior to forming her opinion. Ms Hasson had formed the impression Mr STW thought he had his substance use under control, although it is clear now he was progressing to a relapse even around that time. Ms Hasson had observed that Mr STW had done a number of programs over time already, including being engaged with Fresh Start while on parole immediately prior to being returned to prison on the last occasion, so she considered he needed further ongoing support. However, given Ms Hasson had understood that Mr STW had not relapsed at the time she was preparing her report, she had focussed on more general ongoing support to maintain his sobriety, rather than any kind of rehabilitation programme.81

79. Specifically, Ms Hasson had recommended that Mr STW’s treatment needs could be addressed through individual psychological counselling provided by the FPIT, as well as ongoing treatment for his depression through his treating GP.82 Given his struggles to accept the need to be supervised, Ms Hasson also recommended that Mr STW “be subject to a Supervision Order that is not seen as onerous or overly restrictive,”83 with a focus on counselling and engagement in supervision.

Ms Hasson gave evidence the FPIT work with high-risk, high-need offenders around their criminal treatment needs, which can include deficits in coping skills, emotional regulations, substance abuse, violent ideation, antisocial attitudes and beliefs. She considered the highly specialised team of clinicians was well suited to help Mr STW with his outstanding needs after they had established some rapport and trust with him, accepting they would need to work through some of his anger and frustration at being on an interim supervision order.84

78 T 144.

79 Exhibit 1, Tab 21.1 80 Exhibit 1, Tab 21.1.

81 T 144 – 145; Exhibit 1, Tab 21.

82 Exhibit 1, Tab 21 [114(vi)].

83 Exhibit `, Tab 21 [113].

84 T 147.

[2026] WACOR 3

80. Ms Hasson also explained at the inquest that she did not have any of Mr STW’s mental health information available to her at the time of preparing her report, so although she was aware of a history of depression or chronic low mood and voicing suicidal thoughts, there was no recent information of his fluctuating mental health before her. Ms Hasson had felt Mr STW seemed quite future focussed at the time she saw him, some six weeks before his death, and at that time there had been nothing to suggest any acute risk of suicide.85

81. Dr Wojnarowska also prepared a report in relation to the Restriction Order application. Her report was dated 6 July 2022, so it had been prepared within a similar timeframe to Ms Hasson’s report. Dr Wojnarowska gave evidence that in a case like Mr STW’s where she is writing to the Court under the HRSO Act legislation, her assessment is “very much focused on the future risk of re-offending”86 and the question of whether the person (in this case Mr STW) is suitable to live in the community or should be returned to custody. Dr Wojnarowska had met Mr STW twice for a total period of four hours and reviewed a large number of materials before forming her opinion.

82. Dr Wojnarowska noted in her report that in the past Mr STW had “viewed himself as institutionalized and unable to live a pro social and alcohol and drug free life in the community,”87 despite completing a number of community orders and programs.

From a diagnostic point of view, Dr Wojnarowska observed Mr STW fulfilled the criteria for Antisocial Personality Disorder and Substance Use Disorder. Like Ms Hasson, Dr Wojnarowska had been led to understand Mr STW had successfully maintained sobriety since being released from custody on the interim supervision order, but she acknowledged his risk of relapse was high based on his past history and had expressed the view that any positive urinalysis sample needed to be dealt with immediately as it presented an increased risk of reoffending. Dr Wojnarowska acknowledged Mr STW appeared very motivated to change, but also noted this same degree of motivation and insight had been present when he was released from prison in 2017, and he reoffended shortly afterwards.88

83. In terms of any risk to himself, Dr Wojnarowska gave evidence Mr STW had not presented as someone with significant psychiatric history and he had not presented as depressed when she met with him on 20 and 29 June 2022. He had appeared to be functioning quite well in the community. She remembered he was quite proud of having gained employment and said he was enjoying going to work every day.

Dr Wojnarowska had felt Mr STW would benefit from individual psychological counselling and drug rehabilitation but had not considered he required ongoing psychiatric treatment at that time. Dr Wojnarowska also gave evidence there was no indication at the time she assessed him that he would be distressed about the possibility of continuing with conditions.89

85 T 145 - 147.

86 T 155.

87 Exhibit 1, Tab 22 [33].

88 Exhibit 1, Tab 22 [48] – [49], [105].

89 T 157 – 159.

[2026] WACOR 3

84. Both Ms Hasson and Dr Wojnarowska concluded that Mr STW was a high risk of reoffending in a similar way to his previous pattern of offending if not subject to an order under the HRSO Act. Both experts recommended that Mr STW should engage in individual psychological intervention, and Dr Wojnarowska further recommended Mr STW engage in drug and alcohol specific treatment. It was suggested he be placed on an interim supervision order for a minimum duration of two years to give Mr STW an opportunity to demonstrate his ability to remain drug and alcohol free and adhere to the conditions of the interim supervision order.90

85. Ms Sullivan was involved in authoring the Community Supervision Assessment Report, dated 29 July 2022, for the purpose of the Restriction Order application hearing in the Supreme Court. This report documented his compliance and non-compliance with the interim supervision order conditions and also took into account the psychological and psychiatric expert reports prepared for the hearing.

The recommendation to the Court was for a HRSO Act, interim supervision order, to be imposed with 32 conditions. This was consistent with Ms Sullivan’s understanding that by that time the likely outcome was for Mr STW to remain in the community, subject to a restriction order.91

EARLY EVENTS ON 8 AUGUST 2022

86. Mr STW saw Dr Hodgkinson again at the Homeless Healthcare service on the morning of 8 August 2022. He requested Dr Hodgkinson complete a medical assessment form for the Salvation Army Bridge House detoxification service. The substances he wanted to detox from were amphetamines and alcohol. He also wanted a medical note for his lawyer to use to assist him to bring his medications with him the following day to his court appearance. The medical assessment form for Bridge House specifically asks if the participant has had suicidal thoughts in the past 12 months. In response to this question, a ‘yes’ answer was given, along with the notification that he had no current plans or intent to act on the thoughts.

Dr Hodgkinson recalled that the answer had initially been recorded as ‘no’, but when he had explored Mr STW’s history, he had disclosed he had experienced suicidal thoughts in the previous 12 month period, so Dr Hodgkinson had changed the tick box from ‘no’ to ‘yes’. Mr STW also indicated he was struggling with thoughts of relapse into substance use although he maintained he had not actually relapsed yet.

He was prescribed a short course of diazepam as a backup for the detoxification process, as per Bridge House standard protocol, and Dr Hodgkinson encouraged Mr STW to attend meetings with the in-house Alcoholics Anonymous (AA) group at The Beacon. He also encouraged Mr STW to engage with his family for support.

Mr STW seemed reluctant but did not disclose the reason why.92

87. Importantly, given later events, Dr Hodgkinson formed the impression Mr STW was positive about attending Court the following day. Mr STW mentioned to Dr Hodgkinson that his lawyers thought he might receive beneficial news from the Court and at the time he left the appointment he appeared to be reasonably upbeat 90 T 149, 158; Exhibit 1, Tab 21 and Tab 22.

91 T 135; Exhibit 2, Tab 6.

92 T 13 – 14; Exhibit 1, Tab 24; Exhibit 2, Tab 19.

[2026] WACOR 3 and content. Dr Hodgkinson characterised Mr STW’s mood as “cautiously optimistic, particularly about court the next day”93 and Dr Hodgkinson did not observe any behaviour that indicated he was acutely suicidal. Dr Hodgkinson gave evidence he was very surprised when he was informed Mr STW died by way of suicide shortly after this appointment. He was aware of Mr STW’s history of chronic suicidal ideation, but he had considered Mr STW appeared to be “moving forward with good plans”94 at the time he last saw him and there was nothing that suggested he had any current thoughts or plans to harm himself.95

88. Dr Hodgkinson gave evidence that if Mr STW had indicated he was expecting a negative outcome in Court the next day, he would have put in place some more support contact from Mr STW’s caseworkers at The Beacon and reaffirmed his other options to reach out for help if he felt actively suicidal. However, there was nothing that suggested this was necessary at the time, based on his discussion with Mr STW.

Dr Hodgkinson understood from Mr STW’s account that he had not been using drugs or alcohol recently, and he was unaware of the recent breach of the interim supervision order due to substance use, so he had no information to suggest Mr STW might have been anticipating an adverse outcome the next day.96

89. Mr STW’s last HRSO Act appointment with SOMS police officers was at 12.40 pm on 8 August 2022. The purpose of the meeting was for Mr STW to sign his next notice of reporting obligations forms. Mr STW arrived early for the interview and appeared ready to engage. The interview took about 10 minutes, and it was digitally recorded. Mr STW seemed to be in a positive frame of mind during the interview.

The two officers, Detective Senior Constable McSweeney (Det S/C McSweeney) and Detective Senior Constable Booth, acknowledged that when they had last seen Mr STW it hadn’t been a great day for him as they had been conducting a compliance search at his place of residence. They said they hoped things were looking better for him since that time, and Mr STW confirmed that they were.

Mr STW told the officers that he was preparing for his Court appearance the next day. He indicated he had spoken to his lawyer in preparation for the hearing and had been told it was unlikely he would be taken off the interim supervision order entirely, which he accepted. However, he believed he might succeed in getting some of the HRSO Act conditions removed.97

90. They discussed that although Mr STW was on 35 conditions, which was not considered a lot for a interim supervision order as many of them were standard.

Det S/C McSweeney asked which conditions were causing him the most difficulty and his curfew time was discussed. Det S/C McSweeney gave evidence he would often talk to the offenders about conditions they were struggling to meet, to see if they could help with ensuring compliance before it led to an arrest.98 Mr STW also stated that he was waiting to start a six-week rehabilitation programme at Bridge House and was not working in the interim. He told the officers his family and

93 T 12.

94 Exhibit 2, Tab 19, p. 4.

95 T 2 – 13; Exhibit 2, Tab 19.

96 T 23.

97 T 27, 35 - 36; Exhibit 2, Tab 20.

98 T 27, 35 - 36; Exhibit 2, Tab 20.

[2026] WACOR 3 work colleagues had been encouraging him to continue working but he felt it wasn’t the right time, and he needed to slow down a bit and complete his rehabilitation first.

Mr STW was confident his job would still be waiting for him once he had finished at Bridge House, and he felt it was important to spend some time dealing with his personal issues first.99

91. In the meantime, Mr STW said he was taking anti-depressants, which helped him to think more rationally and assisted him with managing his drug cravings. He said he was occupying himself by watching TV, talking on the phone, playing games, and going for a walk; just generally lying low until he went into rehab. His Community Corrections Officer had reassured him that he would have accommodation available for him after he completed the program, so he was not worried about being homeless.

Mr STW mentioned he had a girlfriend, and the relationship was going well but she lived in the country, and he hadn’t seen her since he had been arrested. It was noted by the officers that overall Mr STW seemed a lot more positive than normal, saying he felt strong within himself. His next appointment was scheduled for 5 September 2022, which would be after his Court appearance. 100

92. No welfare concerns were identified during this last appointment. Both detectives had met Mr STW several times previously as part of his HRSO Act reporting obligations and there was nothing that stood out to them at the time as raising particular concern. The two detectives actually mentioned to Mr STW at the end of the interview that he seemed a lot brighter than they had ever seen him before and noted it was the first time he seemed positive that at least he was out of prison, rather than just being focussed on the restrictions placed on him by the interim supervision order. In response, Mr STW told the detectives that he was focussed on the fact that at least he was out of prison and “if I do the right thing…I’ve got nothing really to worry about.”101 Mr STW mentioned he had seen Dr Hodgkinson to help line up what he needed for the rehabilitation programme and now he just planned to lay low until a place became available. Det S/C McSweeney recalled that after Mr STW left the interview, he discussed with his colleague Mr STW’s presentation, and they both felt that he appeared to be in a positive frame of mind. Neither of them held any welfare concerns for him that day. Det S/C McSweeney gave evidence he was surprised when he was informed the following morning that Mr STW had harmed himself that night, given how he had presented at their meeting.102

93. It was put to Det S/C McSweeney by counsel for Mr STW’s family that sometimes Aboriginal men may tell government officers what they think they want to hear, rather than how they are genuinely feeling. Det S/C McSweeney accepted that there can be differences in how an Aboriginal man might respond to questioning by an official, but commented that “everybody is different.”103 Nevertheless, Det S/C McSweeney agreed in questioning that he believed officers in the High Risk 99 Exhibit 2, Tab 20.

100 Exhibit 2, Tab 20.

101 Exhibit 2, Tab 20 [380].

102 T 28 – 31, 43 - 44.

103 T 39.

[2026] WACOR 3 Serious Offender Team would benefit from receiving specialist training about culturally safe and trauma informed communication, given this case.104

DISCOVERY OF MR STW BY THE BEACON STAFF

94. Information obtained from Mr STW’s phone records show he was sent a text from Legal Aid at around 3.30 pm with details about the meeting time and place for his Court appearance the following day. He appears to have had a short call with another person and then he spoke to Ms Barrett. It seems that Mr STW was still engaging with Ms Barrett, despite what he had told others about the relationship being at an end.

95. Ms Barrett told police she had been in a relationship with Mr STW for approximately three months. She had last seen him in person when he was arrested for the breach of his interim supervision order following a positive urinalysis result. They spoke on the night of 8 August 2022 about the positive urinalysis result. Despite what he had told the SOMS officers that day, Mr STW appeared to be under the impression that he would be sent back to prison the next day for breaching the interim supervision order due to the positive result. He told Ms Barrett he didn’t want to go back to prison. A download of his phone shows Mr STW took a photo of a noose hanging over his door, and another of his bags all packed neatly beside his door. He sent the photos to Ms Barrett sometime after taking them at 6.10 pm.105

96. Ms Barrett later told police she believed Mr STW had already made up his mind to end his life when he sent the photographs, although she tried to talk him out of it.

Sometime after receiving the photographs, Ms Barrett called The Beacon to raise her concerns with the staff. The first call was made at around 10.30 pm. Ms Barrett described Mr STW as generally a ‘happy go lucky’ person and she knew he was not in a good place at the time she made the call. She asked The Beacon staff member to conduct a welfare check on Mr STW.106

97. Mr STW had been seen by a support worker at The Beacon at 3.30 pm at the front reception and again around 5.00 to 5.30 pm. Nothing had seemed out of the ordinary to the staff at either time. Support worker Mariana Balley (Ms Balley) received the call from Ms Barrett expressing concern for Mr STW’s welfare at about 10.30 pm.

Ms Balley knew Ms Barrett had previously lived at The Beacon before being evicted, but she did not know her personally. Ms Barrett said Mr STW had texted her photos of the back of the bathroom door and she was worried about him and asked if a staff member could check if he was okay. Ms Balley thought the reference to the door was unusual, but Ms Barrett did not mention anything related to a concern about hanging or explicitly refer to self-harm, so Ms Balley did not make the connection at that time. Ms Balley told Ms Barrett that she would get someone to go and speak to Mr STW, although at that time it did not appear to her to be an urgent matter.107

104 T 40 - 42.

105 Exhibit 1, Tab 7.

106 Exhibit 1, Tab 7.

107 T 48 – 52, 56; Exhibit 1, Tab 2 and Tab 9.

[2026] WACOR 3

98. After the first call from Ms Barret, Ms Balley spoke to another support worker, Harrison Reynolds (Mr Reynolds), who was about to start his shift. She mentioned the call, but before they could discuss it further, she received another call from Ms Barrett asking if anyone had gone to see Mr STW yet. Ms Balley was unable to leave her post at the reception desk as someone needed to be present to monitor the entry. Mr Reynolds had not started his shift yet, so she radioed her colleague, support worker Mr Michael Holmes (Mr Holmes), who was about to end his shift. She asked if he could go and check on Mr STW. Mr Holmes was in another part of the building when he received the radio call. He returned to reception and spoke briefly to Ms Balley, then went to do a welfare check on Mr STW. Ms Barrett called back again for a third time around this time. Ms Balley later checked the logs and noted all three calls were received within a period of around five minutes. During the third call, Ms Balley reassured Ms Barrett that someone had gone to check on Mr STW.108

99. Mr Holmes had seen Mr STW earlier at the reception area at around 3.00 to 3.30 pm and at that time he had seemed fine. Mr Holmes had also spoken to Mr STW the previous night when Mr STW had come downstairs complaining about Ms Barrett, who he described as his girlfriend. Mr STW had seemed a little angry and alleged his girlfriend had taken his key card. Mr Holmes had suggested he cancel the card. On the afternoon of 8 August 2022, Mr STW did not raise the subject of the key card again. He simply asked Mr Holmes to witness a document, without renewing their discussion from the night before. Mr Holmes did not recall anything out of the ordinary in Mr STW’s behaviour that day.109

100. After speaking to Ms Balley, Mr Holmes went directly to Mr STW’s room on the third floor. He knocked on the door but received no response. He called back to reception and advised he had knocked on Mr STW’s door three times and received no response. Given the time of night, he thought it was possible Mr STW was sleeping. Mr Holmes was given instructions to enter the room and announce himself.

Mr Holmes used his staff access card to unlock the door, and he then opened the door. On opening the door, Mr Holmes saw Mr STW hanging from the bathroom door. He immediately called reception and asked for urgent assistance. He then wedged open the room door, stepped into the room, and approached Mr STW. He intended to try to lift him, but said he was shocked by the sight of Mr STW up close, so he retreated to the corridor and waited for a colleague to arrive. A second support worker arrived quickly, and they contacted emergency services. Mr Holmes then left his colleague with Mr STW while he went downstairs to wait for the ambulance staff to arrive and escort them to Mr STW’s room.110

101. St John Ambulance received the call at 10.40 pm, indicating there was only a total of 10 minutes between Ms Barrett’s first call to The Beacon and the discovery of Mr STW hanging. SJA staff arrived on the scene quickly at 10.44 pm and were escorted to Mr STW’s room, where they found Mr STW suspended from a door with a white bandage like material around his neck. They cut Mr STW down and commenced CPR. After approximately 8 minutes of CPR a shockable rhythm was detected and after a shock was delivered, he showed a return of circulation at 108 T 55, 62 - 63; Exhibit 1, Tab 2 and Tab 9.

109 T 60 - 62; Exhibit 1, Tab 8 110 T 65 – 66; Exhibit 1, Tab 2 and Tab 8.

[2026] WACOR 3 10.56 pm. Mr STW was then transferred by ambulance to Sir Charles Gairdner Hospital. On arrival at the hospital, he required treatment for seizures and then ongoing management was provided in the ICU.111

CAUSE OF DEATH

102. The authorities became aware Mr STW was in hospital due to his GPS tracker. After enquiries established, he was in a critical state, efforts were made to identify and contact Mr STW’s next of kin. Some enquiries were made about whether his GPS tracker should be refitted (noting it had been removed for testing), but it was quickly identified that he would be unlikely to regain consciousness, so it was properly decided that the GPS tracker would not be refitted.112

103. An MRI conducted on 9 August 2022 showed severe global hypoxic-ischaemic brain injury and it was noted Mr STW’s pupils had become fixed and dilated. The following day he commenced treatment for aspiration pneumonia. Family meetings were conducted and ICU doctors discussed with Mr STW’s family the severity of his brain injury. They explained he showed signs consistent with brain death and his prognosis was extremely poor. On 11 August 2022, a decision was made to extubate Mr STW and cease all active treatment. He died in the ICU at 7.30 pm on 11 August

104. Police were notified and a coronial investigation commenced. Mr STW’s identity was later confirmed by fingerprint identification.113

105. An external post mortem examination and CT scan were performed by Forensic Pathologists Dr Junckerstorff and Dr Downs. The external examination showed a middle-aged Aboriginal man with ligature marks on the neck compatible with the supplied ligature that had been taken from the scene. There were a few tiny blood spots (petechiae) on the gums which is a known feature of hanging. There were abrasions on both knees and signs of medical intervention. The post-mortem CT scan showed fractures of the left superior horn of the thyroid cartilage and hyoid bone in the neck, which are again findings that may be seen in hanging cases. Other CT scan findings were swelling of the brain and consolidation of the lungs, consistent with the observations of Mr STW while being managed in hospital immediately prior to his death.114

106. Toxicology analysis showed medications consistent with Mr STW’s medical history.

Alcohol, cannabinoids, and other common drugs were not detected.115

106. At the conclusion of these limited investigations, it was determined that the cause of death could be given without a full internal post-mortem examination. The cause of death was given as complications of ligature compression of the neck (hanging).116 I accept and adopt the opinion of Dr Junckerstorff and Dr Downs as to the cause of death.

111 Exhibit 1, Tab 2.

112 Exhibit 2, Tab 11.

113 Exhibit 1, Tab 2 and Tab 3.

114 Exhibit 1, Tab 5.

115 Exhibit 1, Tabs 5 and 6.

116 Exhibit 1, Tab 5.

[2026] WACOR 3 MANNER OF DEATH

107. The WA Police Force had been notified of the emergency on the night of 8 August 2022. Two police officers from Perth Police Station arrived at The Beacon at 10.48 pm, shortly after the SJA officers. They assisted the SJA officers with resuscitation efforts before Mr STW left in the ambulance. The two officers had observed no visible injury to Mr STW, other than the ligature mark present on his neck. They found the strip of white material used as a ligature on the bathroom floor, after it had been cut by the SJA paramedics. The police officers established it had been torn from a sheet in the room. Mr STW was noted to still have the electronic monitoring device fitted to his right ankle at the time he was taken away by ambulance. The two police officers saw nothing to suggest that another person had been involved in Mr STW’s death and no evidence of criminality.117

108. The police officers had seized Mr STW’s mobile phone on the night he was found hanging. The contents of the phone were later downloaded, and relevant messages and images were identified that appeared to support Ms Barrett’s recollection of events.118

109. Following Mr STW’s death in hospital, Detective Senior Constable Tribbeck and Detective First Class Constable West (Det 1/CC West) of the Coronial Investigation Squad investigated his death. Det 1/CC West obtained the relevant CCTV footage from The Beacon. The CCTV footage was examined and showed Mr STW at the reception at 3.27 pm on the day he died with some papers in his hand, talking to a female staff member. He was also recorded at 5.37 pm walking past through the front door area and past reception. In addition, there was footage of him entering and leaving his room at various times, always alone. In all of the footage, he is depicted as generally calm in demeanour, although the expression on his face is not clearly visible.119 Various staff from The Beacon were spoken to, along with Ms Barrett, and their accounts were consistent with the CCTV footage. At the conclusion of these inquiries, the detectives found no evidence to support criminality or third party involvement in Mr STW’s death.120

110. All of the evidence points to Mr STW hanging himself with the intention of ending his life. There is no evidence to suggest another person was involved in his death and I understand Mr STW’s family accept he died from complications of hanging, and by his own hand. I find the manner of his death was by way of suicide.

FORENSIC PSYCHOLOGICAL INTERVENTION TEAM (FPIT)

111. There was evidence before me that Mr STW was referred to the FPIT shortly after he commenced on the interim supervision order by his SCCO Ms Hill. Soon after he was waitlisted, but he never met a psychologist from the FPIT in the time he was on the interim supervision order prior to his death.

117 Exhibit 1, Tab 2.

118 Exhibit 1, Tab 2.

119 Exhibit 1, Tab 7.1.

120 Exhibit 1, Tab 2.

[2026] WACOR 3

112. As the Team Leader, Ms McNally was aware that Mr STW had disclosed having suicidal thoughts to Ms Hill in February 2022 and that Ms Hill had referred Mr STW to the Department of Justice’s Psychological Services on 15 February 2022. On 17 February 2022, Ms McNally had some communication with Ms Hill about an alert on their computer system identifying Mr STW as posing a risk of self-harm.

Importantly, in the alert that Ms Hill later updated, she recorded that Mr STW had disclosed he was considering suicide and that he had said “he would suicide before returning to prison.”121 Ms McNally endorsed this updated alert, noting that at later meetings his risk to himself was considered to have reduced. Ms McNally commented that in general an upcoming Court appearance was flagged as a risk issue, because it increases stress, but she did not recall anything particular for Mr STW based upon his earlier comment in February 2022.122

113. Ms McNally was asked about this entry at the inquest in the context of whether it was a relevant factor to consider before his scheduled Court hearing, noting his compliance had deteriorated in June and July 2022, leading up to his Court appearance. Ms McNally was aware that Mr STW had not seen a psychologist, as she noted after a COMU Case Management Meeting on 2 March 2022 that the psychological referral remained pending.123 Ms McNally went on leave soon after, and when she had returned from leave in early June 2022, Mr STW still had not seen a psychologist. He did see a forensic psychologist, Dr Hasson, soon after as part of the process for his next Court appearance. However, this was unrelated to any forensic psychological intervention or therapeutic counselling. On 27 June 2022, Ms McNally noted he was still awaiting psychological intervention and remained waitlisted.124

114. On 13 July 2022, following an Interagency Risk Management Meeting, Ms McNally noted that Ms Sullivan had advised there were nil issues regarding Mr STW’s emotional coping/stress management and no mental health issues were raised.125 However, it had been noted that there was an emerging pattern of non-compliance around this time, which had led Ms McNally to recommend a written warning rather than a verbal warning after Mr STW failed to attend a supervision appointment with his SCCO on 5 July 2022. Soon after, on 18 July 2022, Ms McNally became aware that Mr STW had tested positive to methamphetamines on 13 July 2022 and police were informed, which led to Mr STW being charged.126

115. He then admitted intermittent alcohol and drugs use on the interim supervision order and indicated he had quit his job and wanted to engage in a residential drug and alcohol rehabilitation programme. The psychological referral for Mr STW was followed up by Ms Sullivan around this time, noting the referral had been made on 15 February 2022. Ms Sullivan emailed the Manager of the FPIT on 20 July 2022 121 Exhibit 2, Tab 18 [40] and Tab 18.6.

122 T 108.

123 Exhibit 2, Tab 18 [52] and Tab 18.10.

124 Exhibit 2, Tab 18.

125 Exhibit 2, Tab 18.

126 Exhibit 2, Tab 18.

[2026] WACOR 3 and was advised there was no capacity to allocate psychological counselling to Mr STW as the team was at full capacity.127

116. On 25 July 2022, Ms McNally finalised the Progress Case Review, which summarised the concerns around Mr STW’s drug and alcohol use, cessation of his employment and lack of available psychological intervention through the Department of Justice, as well as concerns about the negative impact of his new partner.

However, Ms McNally also commented that Mr STW’s mental health appeared to have somewhat stabilised, in the context she was aware his SCCO thought he seemed a little improved and he planned to see a doctor to get antidepressants prescribed and was keen to engage in substance use rehabilitation.128

117. Soon after, it became apparent Mr STW had tested positive to methamphetamines again on 18 July 2022 and 20 July 2022. No further charges were laid, as he had just appeared in court and the positive urinalysis predated that court appearance, but he was given a written warning. Notes made from the Interagency Risk Management Meeting on 27 July 2022 recorded Mr STW had revealed some suicidal ideation and was now on antidepressants.129

118. On 2 August 2022, Mr STW was given another written warning for deleting messages from his mobile while apparently under the influence of methylamphetamine. It was suspected the messages likely related to his drug use. It was noted in the breach advice that he was still waitlisted for psychological counselling.130

119. Ms McNally gave evidence at the inquest that throughout 2022 she was involved in meetings with FPIT staff about the waitlist “but because there was no movement, those meetings became pointless”131 as there was nothing to discuss. Ms McNally understood it was a staffing issue within the Team that was causing the problem.

120. There is evidence Mr STW’s case was discussed by Ms Sullivan with a member of the FPIT not long before his death and it was noted that he was likely to be going to Bridge House. It was decided it would be best if he addressed his substance use issues first, before engaging with FPIT (assuming the interim supervision order continued) so his referral to FPIT was put on hold on 8 August 2022. Therefore, there was no plan at the time of Mr STW’s death for him to be assessed by a member of the FPIT anytime soon.132

121. Ms Hasson was asked at the inquest her opinion as a psychologist about Mr STW having been waitlisted with FPIT, delaying the onset of counselling. Ms Hasson indicated that given Mr STW was on an interim supervision order, and it is a very limited service with high demand, she was not surprised. Ms Hasson gave evidence she did not think there was any sense of urgency to have Mr STW commence the 127 Exhibit 2, Tab 18 [96(e)].

128 Exhibit 2, Tab 18.

129 Exhibit 2, Tab 18.

130 Exhibit 2, Tab 18 and Tab 18.26.

131 T 102 - 103.

132 Exhibit 2, Tab 9.1 and Tab 11, pp. 537 - 538.

[2026] WACOR 3 counselling with FPIT, although in her ideal world, it would have been great to have Mr STW seen earlier “to have psychological input to deal with all that sort of anger, annoyance and frustration”133 he was feeling about the restrictions. However, at the time she saw him he had seemed quite settled in his accommodation, had a job and was reconnecting with his family, so her sense was there was no pressing need for counselling at that time.134

122. I heard evidence from Forensic Psychologist Dr Nadia Dias (Dr Dias), who is the Director of Assessments and Interventions for Statewide Adult Justice, which encompasses the FPIT. Dr Dias was not in that position at the time of Mr STW’s passing in August 2022, but she was able to speak to the resourcing difficulties the FPIT service were experiencing at that time, as well as currently.135 Dr Dias gave evidence there has been an overall difficulty experienced by psychological services employing qualified clinical staff for a significant period of time across Australia and New Zealand. The Department of Justice specifically has been experiencing skill shortages when trying to recruit people with the relevant competencies to provide the kind of work performed by the FPIT. In addition to difficulties recruiting the right staff, Dr Dias also referred to the fact that the FPIT currently absorbs services that are not funded; relevantly in this case, that includes interim orders. As a result, Dr Dias described the FPIT as a “depleted business area,”136 lacking funding and struggling to recruit and retain appropriately qualified staff.137

123. Dr Dias also referred to another staffing issue, noting that their qualified staff are predominantly women with families, who may require periods of maternity leave or flexible working arrangements as they return to work. This is supported but poses complications in terms of meeting demand for services.138 The FPIT psychologists are all Masters or Doctorate trained psychologists and have specific training and experience in working with offending behaviours and offering targeted interventions for offenders, so they are not easily replaced or backfilled.139

124. At the time of the inquest, Dr Dias explained she had six psychologists working within the team, which due to flexible working arrangements equated to only 4.5 FTE. There is funding for 16.3 FTE, so they were working with approximately one quarter of their full FTE staff load. It is a startling figure and clearly demonstrates the staffing issues being experienced by the service and why Dr Dias used the term ‘depleted’ in relation to the team.140

125. Dr Dias elaborated on the recruitment issue at the inquest, indicating it was underpinned by a lack of qualified people due to a general skills shortage across Australia and New Zealand. This also impacts on other offender mental health services within the Department of Justice. In response, the Department of Justice has set up a Clinical Workforce Shortages Working Group, with key executive personnel

133 T 150.

134 T 150.

135 T 162; Exhibit 1, Tab 35.

136 T 163.

137 T 163.

138 T 163.

139 T 163 – 164; Exhibit 1, Tab 35 [4].

140 T 164.

[2026] WACOR 3 from all of the various areas present along with relevant human resources and recruitment staff, to try and address the skills shortages. Dr Dias emphasised that it is not simply a case of downgrading the level of qualification required for the positions, as “you also need to maintain the integrity of the interventions and be responsive to what the clients are presenting with,”141 given the nature of the work of the FPIT.

126. Dr Dias emphasised the remit or mandate of the FPIT “is around reducing risk of re-offending.”142 It then flows that there is little basis to distinguish between offenders on interim supervision orders or declared final orders, as both categories are assumed to be high risk offenders with high criminogenic need, so their level of need doesn’t change dependent on whether the order is interim or final.143

127. Of note, the most significant change appears not to have come from the distinction between interim and declared orders, but from the change in legislation that has expanded the use of the service from dangerous sexual offenders to high risk serious offenders (beginning in 2020) and any other person on a statutory order such as a post-sentence supervision order or community based order. Dr Dias gave evidence the number of referrals has “exponentially grown”144 and the demand has blown out a lot more than they ever forecast. Given the level of demand and the limited staff available, the service has had to engage in a process of prioritisation, with the people considered to present the highest risk of reoffending and with the highest treatment need prioritised first. The list is, however, also dynamic as the level of risk can alter rapidly depending on what is happening for an individual at any given time.

Accordingly, the waitlist has to be reviewed on a daily level and some people may get pushed further down the list as a new, higher risk, person enters the waitlist.

Dr Dias explained their target is medium and high-risk offenders but based on current demand and staffing the focus is purely on the high-risk and high-need population.145

128. A further challenge in terms of the demand is the reality that many of the people who are engaged with the service present with significant treatment needs and require ongoing intervention and continuity of care to allow them to reduce in risk, so the ability to turn over the waitlist is further reduced. Dr Dias was frank about the limitations of the service to meet the expectation of the judiciary in such circumstances, noting the resource intensive nature of the service. That includes pressure on other resources such as appropriate accommodation services, community services and even the police. As Dr Dias put it, “everybody is experiencing the same stretch.”146

129. Dr Dias gave evidence the FPIT service has put in a submission to include interim supervision order in its service funding, noting it has been providing that service to people on interim supervision order since the onset of the legislation. They are also more able to accurately forecast demand now than when the legislation was first

141 T 165.

142 T 165.

143 T 165 – 166.

144 T 166.

145 T 166 – 169.

146 T 168.

[2026] WACOR 3 introduced. However, any funding increase will not fix the problem of there being insufficient staff nationally to recruit to fill those positions.147

130. A line of questioning explored whether the FPIT would have been able to provide appropriate support for Mr STW if the staffing had been at a level where Mr STW could have been seen at an earlier stage. Dr Dias emphasised that the risk that is being considered is the risk to the community, not the risk an offender may present to self, as that is not the mandate of the FPIT. Therefore, Mr STW’s risk of harm to himself would not have moved him up the waitlist. Instead, Dr Dias considered it would have been appropriate for the risk he presented to himself to be managed by referral to a GP or some other health professional, outside the service, as occurred in this case. I note Mr STW actually saw Dr Hodgkinson on the day of his death in relation to ongoing management of his depression, so it was an opportune time for Mr STW to raise any active suicidal thoughts, if he had been experiencing them.

However, it is possible Mr STW was feeling alright when he saw Dr Hodgkinson, as he indicated, but his mood fluctuated later in the evening.148

131. I also note the evidence of Ms Tara Jones (Ms Jones), who was the Project Manager for Justice Reform for the Department of Justice at the time of the inquest but is usually the Adult Community Corrections Director of Community Offender Monitoring Unit. Ms Jones’ evidence was to the effect there have been no substantive differences in the practices and procedures in the management of offenders, regardless of whether they are dangerous sexual offenders or high risk serious offenders, although the difference may be reflected in the conditions imposed.149 This places significant demands on the services, requiring a level of supervision that is necessary for a sexual offender, but in the context of a much larger pool of individuals.

132. I acknowledge that it is a matter for government to determine the scope of legislation, but the practical impact of the implementation of such legislation on services, resources, and individuals may not always be fully anticipated. The lack of funding for offenders on interim orders is also an example of unexpected flow on to services. Further, the inability to fill the positions funded by the government to provide this service was also not anticipated. However, now that it is known, it is important that the issue is addressed. That may require some critical analysis of the use of interim supervision order vs final orders, as a starting point.

133. Returning to the question of whether Mr STW was provided with sufficient psychological support while on the interim supervision order, I note the evidence of Dr Hodgkinson from Homeless Healthcare was that Mr STW had been referred to multiple supports for drug and alcohol counselling and there was also in-house free psychology services, AA meetings and chaplaincy services available at The Beacon, but it was his impression Mr STW hadn’t been terribly interested in engaging in any of those services other than the Bridge House program. Dr Hodgkinson had specifically discussed referring Mr STW to the private psychologist who came regularly to The Beacon, but he had declined as he felt he was too busy.

147 T 170 – 171.

148 T 170, 172.

149 T 183.

[2026] WACOR 3 Dr Hodgkinson did not wish to speculate as to why Mr STW did not wish to engage with the other services. He simply accepted Mr STW’s choice not to engage with them at that time.150

134. There was an early focus on providing Mr STW with safe and secure accommodation at The Beacon, ensuring he was able to access employment opportunities and skills that would assist him in that regard, and general support and care (including medical care). He was also encouraged to engage with other services that would help him reduce his risk of relapse into substance use and limit his exposure to people/places that would increase the risk of relapse. Whilst he was required to comply with his supervision requirements, it was open to Mr STW to choose to accept or decline the support services on offer.

135. In later conversations, after he had relapsed into drug and alcohol use, Mr STW made some complaints about feeling abandoned by everyone and being ‘set up to fail,’ which appeared to include reference to seeking help for depression but not being given the support, he needed. However, it seems he had been more focussed at the early stages of the interim supervision order on convincing everyone that he shouldn’t be on the interim supervision order. It was only later, when he began to open up about his struggles to remain drug and alcohol free, that it became clearer that he needed more support, and he was indicating he was willing to accept it.151

136. The ability of the staff of the FPIT, which is best placed to provide the kind of psychological support Mr STW required, was significantly impacted by the low levels of suitably qualified staff to fill the positions that were available. Recruitment for these positions remains an ongoing challenge. When the low psychological staffing levels are weighed against the increasing demands that an expanded legislative regime has created, noting it is likely to continue to increase as people remain on the orders for lengthy periods, it is clear that there is a significant problem with the way the HRSO Act supervision and support is able to be provided.

137. There is no simple answer to this complex issue, but the Department of Justice needs to give serious thought to alternative ways for suitable psychological counselling and support to be provided to people like Mr STW. In this case, it is suggested it would have helped him to deal with the anger, annoyance, and frustration he was feeling in a culturally appropriate way. This may have prevented him from relapsing into substance use, which likely led him to feel hopeless about his prospects of remaining out of prison, either through breaching his conditions or reoffending in another way.

150 T 16 - 17; Exhibit 2, Tab 19.

151 Exhibit 2, Tab 11, p. 506.

[2026] WACOR 3 Recommendation 1 I recommend the Department of Justice review the staffing requirements and resourcing of the FPIT, to consider whether there are ways to improve the staffing levels in order to reduce the length of the waitlist. Alternatively, the Department of Justice should explore alternative ways to provide psychological support to supervised offenders subject to both interim supervision order and final supervision orders.

GENERAL COMMENTS ON INTERIM SUPERVISION ORDERS

138. It was submitted by Ms Winmar that at the time of his passing, the State (through the WA Police and the Department of Justice) “had a significant amount of control over his life pursuant to the interim supervision order.”152 The evidence supports this conclusion. There were restrictions on where Mr STW could live, where he could go, who he could communicate with and when he had to be at home. They were all conditions of the court imposed order and it is outside the scope of my role as a coroner to comment on the appropriateness of conditions set by a superior Court. I simply note the reality is that the conditions overall imposed a level of control over Mr STW’s life while in the community, which is necessarily part of a restrictive supervision order. How Mr STW felt about that level of restriction is relevant to consider as part of my consideration of his state of mind at the time of his death.

139. It is apparent from reading the notes of Mr STW’s regular meetings with the police officers monitoring his compliance that Mr STW found the interim supervision order onerous, and he felt it interfered with his ability to get on with his life. This was the first time he had felt so restricted on release, despite having been on parole in the past and engaging in residential rehabilitation programs. Mr STW expressed the belief he had served his time, and he didn’t accept that he presented an ongoing risk to the community. He emphasised to other that he had been well behaved while serving his prison sentence and he was working hard to abstain from substance use and avoid interacting with people who had led him astray in the past. He told police on 4 April 2022 that he was frustrated that he had to answer to people as he believed “the only person he should answer to is God.”153 He told the police officers he would go along with the interim supervision order, but he didn’t agree with it. Mr STW also mentioned that he wished he was able to go out into the country and go hunting, but given his residential condition, curfew and work, it seems that wasn’t possible.154

140. At an early stage after his release, when he was becoming increasingly frustrated with the limits the conditions of the interim supervision order placed upon his movements, Mr STW expressed to his SCCO, Ms Hill, that he felt the interim supervision order “was just white people telling him how to live and all people in 152 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025.

153 Exhibit 1, Tab 19, p. 4.

154 Exhibit 1, Tab 19.

[2026] WACOR 3 authority are white and he has to follow what the Govt says.”155 Ms Hill responded that everyone in society has to conform to rules, and Mr STW appeared to accept that response, but it is clear that Mr STW felt that there was a racist undertone to some of the restrictions placed upon him. He also expressed the feeling that police and Community Corrections staff wanted to lock him up, although he was determined to remain strong and keep out of prison. He also seemed conflicted about his interactions with family while on the interim supervision order, noting he asked about the possibility of attending a family funeral in Kellerberrin, but then changed his mind as he was concerned he might experience triggers that could lead him back to drug and alcohol use. He had recently run into a nephew and the nephew had been drinking alcohol, so he had been forced to cut the meeting off short, and it seems he was worried other associates might also lead him back down that path.156

141. At later interviews it seemed Mr STW had learned to adapt to living under the conditions of the interim supervision order and seemed happy with his new job and was being supported by family and friends. However, he still found some of the conditions very restrictive, such as not being able to go to a restaurant that was licensed premises and some issues with his GPS monitor on the construction site. I also note he mentioned to his Senior CCO that he felt he had lost the ability to live outside prison, a statement he had made in the past.

142. Unfortunately, despite his best efforts to remain sober, it appears that in July 2022 he succumbed to temptation and eventually was charged with a breach of his interim supervision order after using methylamphetamines. He admitted to the drug use and said it was because he was stressed. It also appears he was involved in a relationship with someone who also had drug use issues. I note the evidence of the Community Corrections staff and others involved in the interim supervision order was that his relapse into drug use was not surprising or unusual, and was very unlikely to result in Mr STW being returned to custody, but it seems he was still very concerned this breach would lead him back to prison.157

143. Ms Sullivan, who had been managing his case as his Senior CCO at this time, gave evidence she had been trying to be positive with Mr STW and encourage him to focus on what he was doing well. However, when Ms Sullivan was asked at the inquest whether she was surprised when she heard Mr STW had taken his own life, Ms Sullivan said she was not surprised because of her conversation with him in which he had “expressed his exact intentions”158 to her a week or so earlier.

Therefore, although she found the news very upsetting, Ms Sullivan said it was not surprising to her at the time she was informed. However, Ms Sullivan also gave evidence she had been reassured in the days after Mr STW had made the threat that he was feeling better and in her experience people who threaten suicide don’t usually follow through with it. Therefore, she explained she had not thought he was actively suicidal at the time just before his scheduled hearing, but knowing the threats he had made, it was less surprising news to her than perhaps to others.159 155 Exhibit 2, Tab 17.11.

156 Exhibit 2, Tab 17.11.

157 Exhibit 1, Tab 20.

158 T 130.

159 T 130, 137 - 139.

[2026] WACOR 3

144. Ms Winmar referred to her experience seeing Nyungar people going in and out of custody without help or transitioning support.160 Ms Winmar raised specific concerns about the quality and standard of care provided to her brother in the lead up to his death.161

145. Given her considerable experience in monitoring offenders on high risk supervision orders, Ms Jones was asked her views on interim supervision orders under the HRSO Act and any improvements that could be made. Ms Jones expressed her view interim supervision orders “should be used as an absolute last resort”162 as the offenders find the process of working towards the final court date incredibly stressful. Ms Jones noted the evidence of Mr STW feeling overwhelmed by the process and also very distressed at having to go through intensive psychological and psychiatric assessments as part of the Court process, while also trying to settle into life back in the community. Ms Jones suggested it would be preferable for the application to be made much earlier, well prior to the prospective release date, so that a lot of the assessments can be done prior to the person’s release from custody.163

146. Ms Jones also observed offenders being assessed on an interim supervision order often have an unrealistic expectation that if they comply with the conditions while on the interim order no final order, or at least a much lesser order, will be imposed. This expectation is generally unrealistic. Ms Jones noted the offenders will often find it quite disheartening when their expectations are not met as they see that their good work is not recognised in the way they believe it should, which can then have a negative impact on their mental health. Ms Jones gave evidence in her experience the only time a final order has not been made is in circumstances where the expert reports have indicated the person is not assessed as at high risk of reoffending, rather than in cases where the compliance on the interim supervision order has been high.

This is another reason why doing the reports while the person is still in custody could be beneficial.164

147. At the conclusion of the inquest, I requested the State Solicitor’s Office provide some information as to the decision-making process for seeking interim supervision orders, given the concerns raised at the inquest about the impact on Mr STW by being on an interim supervision order. I am informed the State Solicitor’s Office receives referrals of offenders for consideration of the appropriateness of an application being made under the HRSO Act via the COMU. An application may be made under s 48 of the HRSO Act where the State Solicitor reaches the view that the release of an offender following the completion of his or her sentence gives rise to an unacceptable risk to the WA community. Usually, the referrals occur approximately six to 12 months prior to an offender’s earliest release date, however, lead time can often be less due to short sentences being imposed and the backdating of sentences to allow for time spent on remand. The referrals will be reviewed to assess the risk profile of the offender and to ensure there is appropriate scrutiny of the 160 Exhibit 2, Tab 24.

161 Exhibit 2, Tab 24.

162 T 185.

163 T 186.

164 T 186 - 187.

[2026] WACOR 3 recommendation, “given the nature of the decisions to be made, and the potential consequences of the decision.”165166

148. Once a decision is made that an application will be progressed, I understand there is first a preliminary hearing in the Supreme Court to establish if the Court is satisfied there are reasonable grounds for believing that an order might be made. If the Court is satisfied, then the Court must fix a date for the hearing of an application for a restriction order under s 46 of the HRSO Act and consideration is given to whether the respondent should be detained in custody until the determination of the application or released into the community. The date of the restriction order hearing is usually set after the respondent’s term of imprisonment has expired, taking into account counsel and expert witness availability, so the question of an interim supervision order often arises at the preliminary hearing. In 2022, the High Court of Australia considered the constitutional validity of an aspect of the HRSO Act and it was held by majority that the relevant item of the HRSO Act does not contravene Ch III of the Constitution.167 In his reasons his Honour Justice Edelman relevantly observed that under s 46(2)(c) of the HRSO Act, an interim detention order “should only ever be exercised when there are reasonable prospects of a continuing detention order being made and, even then, only as a matter of last resort.”168

149. I understand that the State Solicitor’s Office is conscious of the above when considering the timing of an application under the HRSO Act, but the State Solicitor’s Office also must work within the context of when the referral is received from the COMU, resourcing (noting the small SSO HRSO Team managed 175 HRSO matters in the previous financial year). Further, it is submitted that a relevant benefit of an interim order, in terms of the requirement to consider the least restrictive option, may be the opportunity to see how an offender responds to the least restrictive option on an interim basis, rather than a continuing detention order.169

150. Having reflected upon the comprehensive information provided by the State Solicitor’s Office in regard to the HRSO Act application process, and why an interim supervision order may be imposed in that context, I do not propose to make any further comments in that regard, other than to emphasise the position is generally that interim supervision orders should be avoided, where timing permits.

CULTURAL AWARENESS AND SAFETY

151. Ms Winmar gave evidence to the effect the terms of Mr STW’s interim supervision order made it difficult for him to spend time with his family and to be on country, both of which were very important to him as a Nyungar man. She commented in her statement that, “It was like the system didn’t want him to do better.”170 It is clear that Mr STW and his sister felt like the interim supervision order made Mr STW’s life difficult and did not provide the level of support and opportunity to rehabilitate 165 Submissions filed on behalf of the Department of Justice and WA Police, filed 21 February 2025, [94].

166 Submissions filed on behalf of the Department of Justice and WA Police, filed 21 February 2025.

167 Garlett v The State of WA [2022] HCA 30; 277 CLR 1.

168 Ibid, [217] (Edelman J).

169 Submissions filed on behalf of the Department of Justice and WA Police, filed 21 February 2025, [1-7].

170 Exhibit 2, Tab 24 [30].

[2026] WACOR 3 himself that he required. Ms Winmar commented that it is hard for men like her brother when they are struggling and want help right away but have to contend with being on waitlists for residential rehabilitation programmes.171

152. Ms Winmar gave evidence that she has previously worked with the Aboriginal Visitor Scheme in WA prisons and is now a board member, cultural advisor and knowledge holder for an organisation called ‘Voice of Hope’, which is an Aboriginal corporation run by Aboriginal women, working to assist incarcerated and formerly incarcerated Aboriginal women with programs and support services to assist participants to connect with culture, identity and family origins and find housing and vocational opportunities to reduce recidivism, domestic violence and addiction.172 Ms Winmar observed from her experience, when people leave prison “it is like a maze for them”173 and she advocates for men to receive proper transitioning services and support similar to what her organisation provide to Aboriginal women, noting culture is important to rehabilitation for Nyungar people and there is more likelihood of success if people coming out of prison can go somewhere on country so that they can heal while reintegrating back into society.174

153. Ms Winmar submitted that although WA Police only provided surveillance role in the management of Mr STW’s interim supervision order, “they failed to interact with Mr STW in a culturally safe and trauma informed way.”175

154. Mr STW’s uncle, Mr Yarran, as a Nyungar man, provided some additional information about the need for a cultural lens when considering the impact of the interim supervision order on Mr STW. Mr Yarran, who works with the Derbarl Yerrigan Health Service, explained that Aboriginal people have a different point of view and Country and Family (in the extended Nyungar sense) are centrally important. Participating in cultural practices, such as hunting to supply food for family and attending funerals of family members, is also very important. Mr Yarran stated that because “Aboriginal people have a different point of view, it’s important that services listen and take advice from Aboriginal people.”176 The need for Aboriginal men to be able to talk to other men about some personal matters is also important. Like Ms Winmar, Mr Yarran emphasised that it is very important for Aboriginal people to work with Aboriginal organisations as they will be able to establish a greater level of trust and also help to instil hope in difficult times.177

155. I note that there was a suggestion that Mr STW was connecting with Wungening Corporation’s ReSet program and THRIVE while on the interim supervision order, but this was not directly managed by the Department of Justice and there is a dearth of information before me as to what specific cultural support and assistance they provided to Mr STW. An enquiry with Wungening by the Court obtained only some 171 Exhibit 2, Tab 24.

172 Exhibit 2, Tab 24 [36].

173 Exhibit 2, Tab 24 [38].

174 Exhibit 2, Tab 24.

175 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025, [15].

176 Exhibit 2, Tab 22 [20].

177 Exhibit 2, Tab 22.

[2026] WACOR 3 information about Mr STW’s contact with drug and alcohol counselling in 2020, and nothing in the lead up to his death while on the interim supervision order.

156. Ms Winmar submitted that the fact that almost half of the people on HRSO’s are Aboriginal or Torres Strait Island, despite making up around 3.3% of Western Australia’s population, “mandates a need for culturally safe care.”178 I accept this submission. The evidence of a number of witnesses, including Dr Wojnarowska and Ms Hasson, supported the conclusion that cultural factors are relevant when trying to assist Aboriginal and Torres Strait Islander people to address their offending behaviours. There is also evidence that Mr STW struggled to disclose his struggles to COMU staff until late in the piece, and he made at least one comment that he felt that white people were in authority and telling him what to do, which suggested he felt there was a lack of cultural awareness in the people with whom he was interacting.179

157. In terms of what cultural awareness training is currently available for CCO’s to ensure that they are able to engage with a man with Mr STW’s cultural background and needs, Ms Hill referred to online mandatory cultural awareness training as an employee of the Department of Justice, but not specific to Adult Community Corrections.180 Ms Jones clarified that this is done as part of the Correctional Officers Foundation Program, at the commencement of their employment, and entails two days of cultural competency training. There is no specific further formalised cultural training for SCCO’s coming in to the Community Offender Monitoring Unit, although there is in-house training, support and mentoring provided in a relatively small team.181

158. Ms Hill gave evidence that, based on her experience, she was “guided by the individual, because what culture is to one individual, and how they identify with their culture and connect with their culture, could be very different from the next person.”182 For example, in relation to Mr STW, Ms Hill recalled he spoke more about wanting to reconnect with his church and his children, rather than specifically about cultural factors, although she accepted generally that as an Aboriginal man family would always be considered an important cultural factor for him. Ms Hill also agreed it would be important to consider whether the interim supervision order could accommodate specific requests such as a person’s desire to reconnect with country.183

159. Ms Hasson and Dr Wojnarowska also agreed cultural aspects are an important factor to consider in addressing the offending behaviour of an individual, although again it seems it would be related back to the particular individual.184

160. As for the concept of ensuring cultural competency in the FPIT, Dr Dias gave evidence her team would welcome an Aboriginal Consultancy Service as a minimum 178 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025, [39].

179 T 153, 160; Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025, [40] – [48].

180 T 92.

181 T 188.

182 T 93.

183 T 93 – 94.

184 T 153, 159 – 160.

[2026] WACOR 3 as their guidance would inform their intervention planning and assessments, noting Aboriginal people are overrepresented across the prison population and that then translates into overrepresentation in the high risk serious offender population.

Another witness provided information that of the 97 individuals on final HRSO orders in November 2024, 40 of those individuals, equating to 41%, identified as being of Aboriginal or Torres Strait Islander descent.185 That is a disturbingly high statistic and underscores the need for cultural considerations to be included in the way the order is structured and implemented, with the understanding that without cultural considerations being included, Mr STW’s comments that he was being ‘set up to fail’ become more understandable.

161. At this stage, given the stretch on services, the focus has been on meeting basic needs such as accommodation and employment to reduce risk of reoffending, as well as looking at an individual’s psychological needs, but Dr Dias agreed that looking holistically at how people function requires consideration of their cultural needs as well in order to ensure they can be independent people who can integrate successfully into the community and have meaningful lives.186

162. Ms Jones gave evidence that Wungening Aboriginal Corporation’s ReSet programme (a service that Mr STW had engaged with upon his release) provides culturally appropriate services as well as an Aboriginal mentor programme for violent high risk serious offenders. ReSet provides accommodation and employment assistance, parenting and family support and also practical assistance such as arranging phone access and transportation to appointments, within a culturally appropriate framework.

Therefore, there is already some recognition of the need for culturally appropriate services for this cohort. Further, as addressed below, it is recognised that all staff need to be culturally aware in their interactions. However, it is questionable whether the Senior CCO’s current level of training addresses this appropriately.187

163. Evidence was provided at the inquest that since Mr STW’s death, there are now Aboriginal and Torres Strait Islander staff at the Community Offender Monitoring Unit, so they can assist with providing cultural advice and guidance to the risk management group.188 Nevertheless, it is clear that it is always an area that can improve. At the inquest Ms Winmar expressed her hope that the people who are writing the policies and programs for people like Mr STW will think about what happened and try hard to really work with Aboriginal people to ensure that there is cultural safety, which will come from more than simply doing some online cultural training. It is important that the Department of Justice listens to the matters that Ms Winmar has raised, based upon her own cultural knowledge and her considerable experience working in this space, and considers whether there can be more meaningful cultural awareness training for Senior CCO’s, noting they will very often be working closely supervising Aboriginal people given the relevant statistics of their inclusion of the expanded supervision orders.

185 T 180; Exhibit 1, Tab 32, p. 13.

186 T 176 - 177.

187 T 184 – 185.

188 T 183.

[2026] WACOR 3

164. As for the support workers at The Beacon, evidence was provided that since August 2022 and onwards, support workers at The Beacon are required to complete e-learnings in Aboriginal and Torres Strait Islander Cultural learning (Introduction, Foundational and Advanced).189

THE BEACON

165. Some submissions were made about possible missed opportunities at The Beacon to intervene. My impression is that the focus of the submissions was on the ability of support workers to respond to the hanging incident, rather than general mental health first aid training. However, I address both.

166. The Salvation Army helpfully provided some information about The Beacon and the role and responsibilities of a support worker, as well as the training provided to support workers, at The Beacon at the relevant time in August 2022 and in 2025. The Salvation Army advised The Beacon is The Salvation Army’s largest residential homelessness facility in Australia, with a total of 102 beds, “providing personcentred, trauma-informed, strengths-based case management, advocacy and support to individuals over the age of 18 who are at imminent risk of, or experiencing, homelessness.”190 All support workers at The Beacon must have a minimum qualification of a Certificate IV in Community Services and it is considered desirable if they have previous experience in the homelessness or human services sector. At the start of their employment they complete an induction, including shadowing a more experienced support worker, and throughout their employment they participate in ‘e-learnings’ on a regular basis.191

167. As explained by some of the witnesses, the support workers provide front of house assistance for residents at The Beacon and assist with service delivery, providing medications, communicating information and advocating for those who require assistance. Since August 2022, The Beacon ‘Front of House’ structure has changed to include further levels of supervision, with a Senior Intake Worker and Team Leader now sharing the responsibility for supervising support workers.192

168. The Salvation Army’s funding for its operations comes from various government and private entities. It was explained that due to the limits of the funding, The Salvation Army is financially constrained in the training it can provide, so it focusses on the training “that best equips support workers for the daily demands of their role.”193 While some staff hold a qualification in Mental Health First Aid (which focusses on suicide prevention rather than response to self-harm incidents), it is not mandatory for the role of support workers for the purposes of their responsibilities, although staff do have regular training in how to understand and appropriately and safely respond to signs of suicide and self-harm.194 189 Exhibit 3.

190 Exhibit 3, p. 1.

191 Exhibit 3.

192 Exhibit 3.

193 Letter provided by counsel on behalf of The Salvation Army dated 12 December 2025.

194 Letter provided by counsel on behalf of The Salvation Army dated 12 December 2025.

[2026] WACOR 3

169. Relevantly to this inquest, online training was, and is, also provided in being suicide aware. This has been strengthened since August 2022, with additional webinars included in the induction training on suicide assessment training, suicide prevention training and debrief and trauma informed care training. Further, The Salvation Army advised that since August 2022, support workers have voluntarily started registering for, and attending, free training at the WA Association for Mental Health, which includes training on ways of working with Aboriginal People and skills training for working with clients with co-occurring alcohol and other drugs issues/mental health issues.195

170. In terms of response to self-harm incidents, The Salvation Army has advised that all support workers have First Aid training, and some are designated as First Aid Officers, but in serious cases of incident or injury, they are instructed to seek the assistance of emergency services. Having considered the timeline of the response of The Beacon staff to this tragic incident, The Salvation Army submitted that the support workers’ response was reasonable and appropriate. Staff went quickly to check of Mr STW after Ms Barrett alerted them to her concerns, and they immediately notified emergency service after Mr STW was found hanging, noting support workers are not medically trained.196

171. Ms Winmar submits that The Beacon support workers would benefit from training to provide emergency first aid. I note that they are generally trained in first aid but not specifically how to respond to a hanging (unlike, for example, prison officers). I agree with Ms Winmar that The Beacon staff are statistically more likely to encounter people experiencing poor mental health, given the cohort of residents, and it would be ideal if they were trained to respond to self-harm incidents. However, even with proper training, it will depend to a certain extent upon the resilience of the individual as to how they respond in a crisis, like it will for any person. In my view, the staff responded appropriately by calling emergency services. Although it would have been ideal if some steps had been taken to remove the ligature and commence CPR, there is no direct duty of care on The Beacon staff to do so, given their role.

SUBSTANCE AND PSYCHOLOGICAL COUNSELLING

172. On the evening of 8 August 2022, Mr STW hanged himself in his room at The Beacon hostel with an intention to end his life. He was discovered by hostel staff shortly after his girlfriend requested them to check on his welfare. They called emergency services for help and Mr STW was taken by ambulance to hospital and provided with intensive medical care, but he had suffered an irreversible brain injury, which led to his death on 11 August 2022.

173. Notably, Mr STW was found hanging the night before he was due to appear in the Supreme Court for further consideration of the State’s application for Mr STW to be placed on a High Risk Serious Offender order. He had received a number of verbal warnings in relation to non-intentional breaches of conditions of the interim supervision order, such as briefly entering an exclusion zone, and more recently he 195 Exhibit 3.

196 Letter provided by counsel on behalf of The Salvation Army dated 12 December 2025.

[2026] WACOR 3 had been charged with breaching an order not to use alcohol or illicit drugs after one of his urine samples tested positive for methylamphetamine. Although he had seemed positive about the Court hearing when he had spoken to supervising police officers and his doctor that day, it seems that he was ruminating on whether the recent charge relating to illicit drug use would result in him being returned to prison.

I understand this was not likely to occur, and Mr STW had been informed the most likely outcome would be that the interim supervision order would convert to a final order. However, Mr STW appears to have been focussed on what the worst case scenario that night and I am satisfied that at the time Mr STW fatally self-harmed, he was worried about his Court hearing and genuinely concerned that he might return to prison.

174. Whilst Mr STW was subject to supervision and was engaging with a doctor and support workers at his residence, it does not appear he was receiving any counselling or psychological report at this time. It had been suggested by Ms Hasson, when completing her report for the upcoming final order hearing, that Mr STW would benefit from some individual psychological counselling when engaging with the FPIT, but he was on a waitlist to see them due to the high demand and their limited available staff, so he had not seen anyone from FPIT prior to his sudden death.

Ms Hasson gave evidence at the inquest that she had thought that the highly qualified clinicians in the FPIT would have hopefully been able to help him work through his anger and frustration at being on an interim supervision order. However, the focus would have been on ways to reduce his risk to the community, rather than on any risk to himself.

175. It is relevant that in June 2021 Mr STW told a prison officer that he had put a belt around his neck prior to coming back to prison due to feelings of shame and disappointment at relapsing into drug use, leading to his return to incarceration.

Given the proximity of Mr STW’s hanging to his scheduled court hearing, it is apparent Mr STW was in a similar mental state in August 2022. While the supports the conclusion he was unlikely to be returned to prison, in his deteriorating mental state he could only focus on the worst case scenario, which is what had happened to him in the past, and he acted out in response.

176. It is difficult to be certain that if more psychological counselling had been offered to Mr STW as part of his interim supervision order he would have engaged with the counselling. He had displayed a general reluctance to engage with the interim supervision order and he had declined a referral by his doctor for counselling services in the community. However, if psychological counselling had formed part of his management through the FPIT then he would have been required to attend all appointments, as one of the conditions of his interim supervision order, so there would have been an opportunity for experienced clinicians to try to work through some of Mr STW’s reasons behind not wanting to participate in counselling.197 As he never started sessions with an FPIT psychologist, it is purely speculative as to whether this might have altered the course of events, but it was a possibility. I agree with Ms Hasson that psychological counselling should ideally have been available to Mr STW as part of his HRSO, especially as this was a listed intervention to manage 197 Exhibit 1, Tab 17.

[2026] WACOR 3 his risk of re-offending. Psychological support may have assisted Mr STW to manage stressors associated with the restrictions the interim supervision order placed upon his life, which may have assisted him not to relapse into substance use or alternatively, may have helped him to maintain a more positive mindset in the face of his lapse and avoid catastrophising about the consequences.

177. Further, there is the important issue of substance use support. Mr STW had a clear risk associate with substance abuse and his Risk Management Plan listed substance abuse as his first behaviour requiring management. The response appears to have been to monitor him to see if he had relapsed into use, without any supports to help him abstain from drug and alcohol use.198 Mr STW had taken his own steps with his doctor to be admitted to a drug and alcohol detoxification centre, and it appears his referral to FPIT was put in abeyance to allow him first to attend Bridge House. I find it surprising that the onus was put upon Mr STW to arrange this, and was not facilitated as part of his supervision, given substance use was a primary factor in his offending history and he was required under the terms of his interim supervision order to abstain from illicit substance use. I acknowledge Ms Sullivan was supportive of the steps Mr STW was taking in this regard, and she helped to follow up his referral, but it appears to me that more could have been done by the Department of Justice to arrange substance use rehabilitation in the circumstances. Simply monitoring his compliance through urinalysis in my view is not enough, even if the focus is simply upon ensuring he abstains for the protection of the community. The community would be better protected by the Department of Justice resourcing and facilitating the kinds of treatment and supports Mr STW required to maintain abstinence.

178. Mr STW’s second risk factor was increased levels of stress and emotional nonmanagement, and it was noted that he would liaise with the appointed psychologist as part of the risk management plan. However, again this did not occur. Due to the demands on FPIT as a result of the expanded scope of supervision orders, and issues with recruiting appropriate staff, there was a lengthy waitlist. This was well known at the time by COMU staff and remains an ongoing concern.199

179. Ms Winmar submits that the COMU failed to provide an alternative intervention for Mr STW, despite knowing he was unlikely to receive any support from the Department of Justice’s FPIT. Similarly, Ms Winmar submits that the COMU out to have done more to assist Mr STW to engage in specific substance abuse counselling and support, given his known risks. Ms Winmar points to the fact that even after Mr STW produced a positive urinalysis reading and admitted to substance use, no steps were taken by COMU staff to assist him further to receive psychological or substance use targeted counselling, other than noting he was trying to gain a place at Bridge House.

180. In that context, Ms Winmar points to the many warning signs that COMU could have identified that Mr STW was struggling and that his mental health was deteriorating, including:200 198 Exhibit 2, Tab 7.

199 Exhibit 2, Tab 7.

200 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025, [35].

[2026] WACOR 3 a. Mr STW had quit his job; b. He told COMU he was not enjoying prayer anymore and had stopped going to church, which was usually a big part of his support system; c. He had stopped going to the gym; d. He had stopped being transparent with COMU staff; and e. He had relapsed into methamphetamine use, which had led to consequences of Magistrates Court proceedings, as well as possible consequences for his Supreme Court proceedings related to his interim supervision order.

181. Mr STW had a known history of suicidal ideation and had expressed threats to harm himself to COMU staff while on the interim supervision order, which had previously led to some steps being taken by his CCO to follow him up at The Beacon. However, in this case Ms Winmar submits there were missed opportunities for the COMU staff to do more to assist Mr STW, both by providing the psychological and substance use support he clearly needed, either through earlier engagement with the FPIT or through a private resource, preferably one that was culturally safe.201 I accept the validity of Ms Winmar’s submissions. I agree that there was a gap in the supervision of Mr STW, in terms of providing him with appropriate psychological support and substance use counselling and support, when they were identified as his primary risk factors for reoffending. It was obvious to his supervisors that Mr STW was struggling and beginning to relapse into drug use, and his mental health was also deteriorating, but there were no structures in place to provide immediate supports to him in that context. In my view, that is a failing in the current HRSO Act regime, both from the perspective of the people being managed on the orders who need help to rehabilitate and the community, who will benefit from the risk of the person’s reoffending being reduced.

182. While I accept Mr STW’s death was an impulsive act, and he did not communicate to anyone other than Ms Barrett his plan to self-harm on that day, there were a number of red flags that his mental state was deteriorating in the lead-up to his death.

More supports during the order, including psychological and substance use counselling, might have made a difference to the tragic outcome in this case.

PATHWAYS TO CHANGE

183. My focus in this inquest was not to scrutinise the court proceedings that led to Mr STW being placed on the interim supervision order. Rather, my focus was on the events that led Mr STW to decide to take his own life, and to consider whether there might have been more supports offered to him in the difficult transition from being in custody and being released but on a restrictive regime that might have led to a different outcome. Any lessons that can be learned in this exercise could have important implications for others, given the overrepresentation of Aboriginal men in custody in Western Australia and on orders under the HRSO Act.

201 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025, [35].

[2026] WACOR 3

184. Ms Winmar submitted that the evidence of Dr Dias, in particular, supports the conclusion that the HRSO Act is not working in practice as it was intended, since the expansion of the type of offender managed on these types of intensive orders, and noting that the interim supervision order in particular were identified as problematic.

Ms Winmar submits most notably, there is no obligation or guidance in the current policies guiding the management of offenders on HRSO’s in relation to:202 a. steps to be taken to assist with the person’s rehabilitation; b. what is expected in relation to mental health support; and c. Providing culturally safe care.

185. Ms Winmar submitted that the management of people on HRSO’s is ‘compliance’ focussed, with no expectation that SCCO’s will assist clients to find or receive support, but this effectively sets them up to fail, as Mr STW maintained. Further, the way in which Mr STW’s breaches were managed, with repeated warnings for what were described generally as inadvertent or ‘technical’ breaches of conditions of his interim supervision order, inevitably caused Mr STW frustration and increased his concern that he would be returned to prison. Despite the intention to take an individualised approach to these high risk offenders, due to lack of resourcing and a ‘compliance’ focussed approach, the orders (or at least interim orders) are not tailored to the individual risks and needs of these offenders.203

186. As Ms Winmar submits, “such a lack of individualisation in the conditions and management of a person on an interim supervision order cannot be said to be adequately protecting the community or facilitating the person’s treatment and support as the HRSO Act intends. When it is considered within the context that these are people who have served their sentences but are being managed to reduce their ongoing risk to the community, in my view more needs to be done to help them to manage the underlying causes of their offending behaviour, as well as monitoring their compliance with the terms of the court imposed order.204

187. Further, I note the evidence of Dr Dias in relation to seeking funding for the FPIT service to include interim orders, although that is within the context that there are still ongoing recruitment issues that are unlikely to be resolved just by increased funding. In that context, there was evidence before me to suggest that interim orders should be avoided, wherever possible, and instead the appropriate enquiries and reports should preferably be prepared while the offender is still in custody serving their sentence, to avoid the need for interim orders being imposed at all. This was the evidence of Ms Hill, who expressed the view it would be best practice if additional work done was before a person is released.205

188. Ms Winmar submitted that the management of Mr STW on the interim supervision order by WA Police and the Department of Justice was only risk focussed and failed to be culturally safe, trauma-informed or rehabilitative. Responsive submissions 202 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025, [55].

203 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025, [59] – [64].

204 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025, [72].

205 T 77.

[2026] WACOR 3 made on behalf of the WA Police and the Department of Justice suggested that the relevant staff already received sufficient training as part of their general training.206 When considering that the aim is to reduce an offender’s risk of reoffending, I consider a more holistic approach needs to be taken, particularly given the high number of Aboriginal and Torres Strait Islander people being managed on these orders. With that in mind, I make the following recommendations: Recommendation 2 I recommend WA Police and Department of Justice staff involved in supervising persons on HRSO Act orders should receive regular training in culturally safe and trauma informed interactions, above and beyond the standard cultural awareness training provided to staff as part of their standard agency induction and training.

Recommendation 3 I recommend the Department of Justice amend the policies for HRSO Act orders to ensure that Community Corrections Officers are required to ensure a person subject to the order (interim or final) is offered appropriate psychological and substance use support related to their identified risk factors from the outset of the order. If the FPIT does not have the capacity to provide that support, then appropriate alternatives should be sourced to provide that support within the framework of the Department of Justice’s overall supervision requirements.

189. Ms Winmar also submitted that an independent Aboriginal and/or Torres Strait Islander should sit at the Risk Management Group meetings to provide advice and guidance regarding cultural matters. In response, the Department of Justice submitted that it is not appropriate for an independent person to be privy to confidential and sensitive personal information in the case management of HRSO’s. However, the Department of Justice supports the use of cultural mentors/advisors for individuals and indicated it would support an independent Aboriginal and/or Torres Strait Islander representative at the HRSO Review Committee as an alternative.207 Acknowledging the issues of confidentiality, I am prepared to adopt the Department of Justice’s recommendation, as an alternative to the submission of Ms Winmar.

206 Responsive Submissions Filed on behalf of the Department of Justice and WA Police, filed 10 March 2025.

207 Submissions filed on behalf of Kerry-Ann Winmar dated 21 February 2025, [76(c)(iv)]; Responsive Submissions filed on behalf of the Department of Justice and WA Police, filed 10 March 2025. [33].

[2026] WACOR 3 Recommendation 4 I recommend the Department of Justice ensure that there is an independent Aboriginal and/or Torres Strait Islander representative at HRSO Review Committee meetings.

CONCLUSION

190. Mr STW was a Whadjuk and Ballardong Nyungar man who grew up in a close, loving family but unfortunately began using drugs and alcohol, which resulted in a pattern of offending that led to a considerable portion of his adult life being spent in custody. His substance use and history of reoffending also had a detrimental impact on his mental health at times. Due to his offending history, Mr STW was considered to be a risk to the community, so prior to the end of his last period of imprisonment an application was commenced for Mr STW to be subject to the HRSO Act. An interim supervision order was made, and Mr STW was released on an interim supervision order under the HRSO Act. Mr STW had been on parole before, but this type of restriction order regime was new to him. He found the nature of the restrictive order difficult to comprehend and he struggled to comply with the many conditions.

191. Nevertheless, Mr STW appeared to have a positive mindset and was trying very hard to avoid drugs and alcohol and anyone who might tempt him to fall back into substance use. In the first few months after his release, Mr STW was doing driving lessons, had found a job he enjoyed, was attending church and spending quality time with family. Everything seemed to be going reasonably well, although he was open about his struggles with the level of constraint that the terms of the interim supervision order placed upon his freedom and his frustration at what could be described as ‘technical’ breaches. During this time, he was not receiving any supportive counselling or formal substance abuse support as part of his supervision, despite voicing thoughts of suicide at least once.

192. Mr STW’s resolve eventually began to unravel and he relapsed into drug use in the context of a new relationship. He was fined for using an illicit drug and was counselled about the risk he might be returned to prison if he wasn’t compliant with the interim supervision order. He appeared to recognise the risk his substance use presented, so he began to seek a placement in a residential substance use rehabilitation programme. It was not going to be easy, as he had been unsuccessful in completing such a programme before, but he had the support of his community corrections officer, and he obtained a referral through a GP. He had not obtained a place in a program prior to his next HRSO Act hearing date and he was not receiving any kind of supportive counselling or substance abuse counselling in the interim.

193. The night before his Court appearance, Mr STW hanged himself in his room at The Beacon. I am satisfied he did so as he had become concerned, he might be returned to prison for breaching the terms of his interim supervision order, although in reality this was unlikely to occur. Mr STW appears to have acted impulsively and

[2026] WACOR 3 gave no warning to anyone of what he was going to do except his girlfriend. She raised the alarm and staff at The Beacon went to check on him, but sadly it was too late.

194. In my view, there were missed opportunities to provide more support to Mr STW when it became apparent, he was struggling to comply with the terms of his interim supervision order. While I accept the focus of the interim supervision order and compliance is the protection of the community, the community would have been better protected by ensuring Mr STW had appropriate support to avoid drugs and alcohol, which were known to be his primary triggers. If Mr STW had been offered psychological support at an earlier stage, he may have better able to resist the temptations of drugs and alcohol and engaged in less catastrophic thinking in the lead-up to his court appearance. Ensuring that support was also culturally safe and trauma-informed, may also have made a difference to Mr STW’s state of mind and his ability to stay out of trouble.

195. Given there is likely to be an ever increasing number of people subject to these types of restrictive supervision orders, and many of those people are likely to identify as First Nations people, it is important for lessons to be learned from this sad case for the future.

I certify that the preceding paragraph(s) comprise the reasons for decision of the Coroner's Court of Western Australia.

DEPUTY STATE CORONER S Linton

23 JANUARY 2026