Inquest into the death of BRANDON GEOFFREY SAGER
Deceased
Brandon Geoffrey Sager
Demographics
43y, male
Date of death
2016-11-06
Finding date
2021-12-21
Cause of death
asphyxia due to hanging - suicide
AI-generated summary
Brandon Sager, 43, died by suicide at the Brian Hennessy Rehabilitation Centre while subject to a psychiatric treatment order. He had a long history of schizophrenia and prior suicide attempts but had shown no signs of suicidal ideation in the three years before his death. He was assessed by a psychiatrist one week prior and explicitly denied suicidal ideation. Staff observed nothing to suggest heightened risk immediately before his death. The coroner found no evidence that the quality of care, treatment, or supervision contributed to his death. However, the case identified a public safety issue regarding non-ligature-proof door handles at the facility. This has subsequently been addressed through retrofitting with anti-ligature fittings at successor facilities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- rapid onset of hopelessness
- non-ligature-proof door handles at facility
Coroner's recommendations
- Ensure anti-ligature fittings in mental health facilities, including non-weight bearing wardrobe curtains instead of doors, anti-ligature drawer fittings, and anti-ligature bedroom fittings
- Conduct regular environmental safety checks on shift-to-shift and as-needed basis to review ligature risk in bedrooms
- Ensure all staff working in mental health units complete anti-ligature training including theory and emergency safe removal procedures
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