Warning: This story contains the name and images of a deceased Indigenous person.
Ricky-Lee Cound did all the right things to try and get help on the day he died by suicide in his prison cell.
He warned prison staff he was thinking about self-harm, he asked to be monitored, and fellow inmates even tried desperately to raise the alarm on his behalf. But they were all ignored.
Ricky-Lee Cound died in a prison cell three years ago.Credit: Facebook
On the third anniversary of Cound’s death, the Coroner’s Court of WA has released its findings following an inquest held last year.
Cound was the first adult prisoner in WA to die in custody who had been formally diagnosed with fetal alcohol spectrum disorder (FASD).
A few weeks before his death in March 2022, Cound had been transferred to Hakea Prison from Acacia due to his involvement in a riot, which led to him being placed on the at risk management system (ARMS) due to self-harming.
The day before he died, Cound tested positive to COVID.
The next day, he was taken off ARMS.
Three hours later, he requested to be placed in a CCTV-monitored cell so he didn’t self-harm, but that request was ignored and he was given food instead.
“The prison officer who answered Mr Cound’s cell call arranged for a senior prison officer to speak to Mr Cound,” Coroner Philip Urquhart’s findings stated.
“After a short conversation with Mr Cound, the senior prison officer arranged for him to be given a radio and when that was not available, Mr Cound was provided a breakfast pack.
“He was not placed in a cell with CCTV monitors, nor was he placed on ARMS.”
Urquhart said the “failure” by Department of Justice staff to place Cound into a safe cell contributed to his death a few hours later.
“Had he been in a safe cell, the risk of Mr Cound being able to end his life would have been significantly lower than the level of risk that existed within his cell in B Wing,” he said.
Half an hour after Cound sought monitoring, he and two other prisoners in the same unit broke their cell doors’ viewing windows and threw broken glass and parts of fans from their cells into the corridor.
“Although there was broken glass inside Mr Cound’s cell, his cell was not checked or cleaned by prison staff,” Urquhart’s report stated.
It was more than two hours before officers checked on Cound and saw him standing in his cell.
But 10 minutes after that, a fellow inmate made a cell call stating Cound was “cutting up” and “blood’s everywhere”.
Instead of attending to him, officers decided to deal with a water spill instead, stating it was “a potential hazard”.
During that time, prisoners were making cell calls asking for Cound to be checked on as they had not heard from him in some time.
Ricky-Lee Cound died in his prison cell after calling for help in 2022.Credit: Facebook
At 7.26pm Cound was found unresponsive. Extensive resuscitation efforts were performed by prison officers, prison nursing staff and attending ambulance officers, but Cound could not be revived and later died at Fiona Stanley Hospital.
“Although the Coroner accepted the reasoning behind the prison officers attending D Wing before their check on Mr Cound, there were several missed opportunities identified that had they been taken, were likely to have reduced the time it took for the check on Mr Cound to take place,” Urquhart’s report said.
Urquhart also added that he was “not satisfied” that the care and management of Cound’s FASD was “appropriate”.
“The Coroner found that the Department was responsible for that as the Department’s Health Services were required to perform in an under-staffed and under-resourced environment within the prison estate,” the report stated.
“Although the Coroner was satisfied some improvements and changes had been made by the Department since Mr Cound’s death, a lot more still needed to be done to lower the risk of suicide amongst vulnerable prisoners, particularly those who are First Nations.”
Cound’s story is eerily similar to that of 16-year-old Cleveland Dodd who died in October 2023 after also warning prison staff he was contemplating self-harm.
Dodd’s story raised concerns about juvenile detention and caused national outcry after an internal review found prison staff were watching movies when he was dying in his cell.
“The Hakea prison staff were notified that he should have been put on suicide watch but unfortunately cries for help were not heard,” Cound’s stepsister Angela Howell said in a statement three years ago.
“This has shattered our family.
“He was more than just another black death in custody, he was a son, a brother, an uncle, a nephew, a grandson and a good friend to many.”
Urquhart made eight recommendations after Cound’s death, with an emphasis on the treatment and care of prisoners with FASD and other intellectual disabilities, and on reducing the risk of suicide among prisoners.
For 24/7 crisis support run by Aboriginal and Torres Strait Islander people, contact 13YARN (13 92 76).
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