Jomen Blanket: ‘Grossly inadequate’ safe cell shortage allowed Indigenous man to take his life, coroner finds

Warning: Distressing content A Noongar and Torres Strait Islander man was left in his cell, where he was able to take his own life, because there was nowhere else for him to go. That is the conclusion WA Coroner Philip Urquhart reached in his findings following the inquest into the 2019 death of Jomen Blanket, handed down on Wednesday. The inquest, held in July 2022, was told that between February and June 2019 the 30-year-old father-of-three had been suffering from hallucinations, was hearing “command-based” voices telling him to do things and was deeply disconnected from reality. In the months after he was jailed, he made repeated suicide attempts — cutting himself in February, and bashing his head against the wall in his cell a month later — and had been moved in and out of medical observation cells as a result. A week after that he told his cellmate he wanted to hang himself, before repeating his threats to his mother Karen Blanket on the phone. On April 22, after he received a letter denying his parole release, he showed prison staff a noose he’d fashioned out of bed sheets. The morning of his passing, on June 12, Mr Blanket was being escorted back to his cell after getting a blood test when he requested the prison’s counselling services — but he changed his mind almost immediately and walked away. The last time he was seen alive, he was waving goodbye at the door of his cell. Worried, the prison officer who escorted him attempted to telephone the prison counselling service, but no one from that team was in the office as they were at a staff farewell party. She sent an email about arranging his transfer to a medical observation cell. Less than an hour later, while waiting for a response, she went to check on Mr Blanket, and found him unresponsive. In his findings, delivered this week, Coroner Urquhart said it was clear jailers had recognised Mr Jomen was agitated on the morning of his death, and had attempted to have him relocated to a safe cell, but had failed to monitor him during the “unanticipated delay” in that process - “due to the chronic shortage of safe cells at Acacia”. It is a shortage, described as “grossly inadequate”, that still presently exists, with only six such safe cells available out of 1059 cells. “This delay, together with a failure to properly monitor Mr Blanket, provided the opportunity for him to take his life,” Coroner Urquhart said. He also found that more should have been done by staff sooner, given Mr Blanket’s “precise suicide plan ... known to Acacia staff for about eight weeks. “Mr Blanket should not have been allowed to close his cell door at a time when he was thought to be at an elevated risk of self-harm,” he said. Coroner Urquhart also found that several red flags were missed by staff, that communication between jailers and psychologists and counsellors was siloed, and that the privately-run prison did not have a suitable therapeutic care unit. “Regrettably, the beginning of Mr Blanket’s supervision, treatment and care was anything but ‘culturally appropriate’,” he said. He called for several urgent reforms, including a recommendation for immediate funding for a therapeutic care unit to treat mentally unwell prisoners and for psychological and counselling support to be provided after an inmate is informed of a parole decision. Mr Blanket’s mother Karen Blanket said she hoped the coronial findings pushed the WA Government and Serco to take urgent action. “I am still heartbroken about the death of my son. I live with the loss and the grief every second of the day. I don’t want any mother to have to go through what I have had to bear,” she said. “I drove out to the prison three times when Jomen threatened to hurt himself. I told the guards about my concerns but they did not pass the information on to the supervisor.” George Newhouse, principal solicitor of the National Justice Project, said Coroner Urquhart’s recommendations were significant but did “not go far enough” “Aboriginal Medical services need to provide culturally safe therapeutic health care in WA Prisons,” he said. “The prison system needs to listen to family members. Families know their loved ones well; they need a voice, they need to be heard.” Lifeline: 13 11 14