A West Australian coroner has criticised the “decrepitude” of Broome prison, saying the outdated facility and lack of resources meant staff were unable to deal with high mental health risk inmates such as an Aboriginal man who took his life at the prison in 2015.

Mr Jackamarra, 36, who was also known as Mr Hajinoor, was found dead in the shower block at Broome prison at 2.15pm on 16 December 2015, less than three hours after being transferred to the prison from the court cells and four and a half hours after being remanded in custody. He had been granted bail but was waiting until his uncle, who was working out of town, could return and post bail.

Jackamarra’s family asked that his first name not be used for cultural reasons.

He had a long history of mental illness, including a personality disorder linked to substance abuse, and had multiple reported self-harm attempts in both the WA and Northern Territory prison systems, as well as in the community in Broome. An earlier psychological assessment found Jackamarra was at chronic risk of suicide, which could “destabilise to acute risk very rapidly”.

But despite that history he was not flagged as being at risk of self-harm by officers at Broome prison on the day of his death, and the prison did not have access to medical staff who would have been able to conduct a mental health assessment.

Concerns that he might be at risk of self-harm were raised by security officers in the cells attached to Broome magistrates court, where Jackamarra was taken immediately after his court appearance that morning, but paperwork setting out those concerns, including the fact that he had been prescribed daily mood stabilisers but did not have that medication with him, was not forwarded to the prison.

The court security services were contracted to Serco, but the private company lost its contract to another private operator, Broadspectrum Australia, in 2017.

In a lengthy report released on Wednesday, almost seven months after a three-day inquest was held in Broome, coroner Evelyn Vicker said that while the procedures for transferring documentation were not followed, it was not clear whether that would have made a difference in this case.

“The reality of the situation for staff at [Broome prison] on 16 December 2015 was that there was no therapeutic alternative to keep an inmate safe in the circumstances of Mr Jackamarra,” she said. “This was regardless of the transfer of documentation or otherwise. Mr Jackamarra was not asking for help with his state of mind nor was the extent of his destabilisation clear.”

Vicker said the prison system was “ill adapted to deal with these issues no matter how well-meaning individuals in the system are”.

She said the prison was in a state of “decrepitude” when she visited in 2018, despite a $11.2m refurbishment in 2011 and further upgrades in recent years.

“It is a situation which prison officers at [Broome prison] in December 2015, with depleted resourcing and no good access to full medical services, could not hope to address,” she said.

“Realistically, it is one most prisons cannot address adequately when the fact of the [incidence] of mental health problems is so high in the prison population … To try and address these issues without the availability of medical or counselling resources is unacceptable.”

Vicker said it was not appropriate for prison officers to conduct mental health assessments and said that should be carried out by trained psychiatric liaison nurses with access to “all available relevant information”, including from medical services.

“Confidentiality has no place where there is a duty of care to minimise risk,” she said.

She made six recommendations including improved information sharing between the prison system and medical services, and putting CCTV cameras at the entry to showers so they could be better monitored.

• In Australia, the crisis support service Lifeline is 13 11 14.