Coronial
ACThospital

Inquest into the death of Brontë Haskins

Deceased

Brontë Elouise Haskins

Demographics

23y, female

Coroner

Coroner Stewart

Date of death

2020-02-21

Finding date

2023-03-08

Cause of death

Hypoxic-ischaemic brain damage due to self-inflicted hanging with intention of taking her own life

AI-generated summary

Brontë Haskins, aged 23, died by suicide via hanging on 18 February 2020, three days after her release from custody on bail. The inquest identified multiple systemic failures in supervision, assessment, and coordination between services rather than individual clinical failures. Key issues included: inadequate bail supervision (one officer managing 120-130 cases with minimal resources), delayed CADAS assessment (scheduled one week post-release despite known drug use and suicide risk), failure to arrange mental health bail conditions despite documented suicidality in custody, and loss of opportunity when Access Mental Health failed to correctly triage a call from her mother describing acute psychosis. While no individual clinician was culpable, the coroner emphasized that therapeutic gaps and service delays created circumstances where involuntary detention might have prevented her death. Recommendations focused on resourcing, bail assessment reports incorporating mental health information, and earlier service engagement.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

psychiatryemergency medicineaddiction medicinecorrectional health

Error types

systemdelaycommunication

Drugs involved

heroinmethamphetaminecannabis

Clinical conditions

suicidal ideationopioid dependenceamphetamine dependencepolysubstance use disorderdrug-induced psychosismental illness

Contributing factors

  • inadequate bail supervision due to resource constraints
  • delayed CADAS assessment and monitoring
  • failure to establish mental health bail conditions despite documented suicidality
  • loss of opportunity in Access Mental Health triage call - failure to correctly categorise presentation
  • lapse into illicit drug use post-release
  • lack of coordination between services
  • no pre-bail assessment report to inform magistrate of mental health vulnerabilities
  • week-long gap between release and CADAS appointment

Coroner's recommendations

  1. Minister for Corrections and Attorney-General be made aware of evidence regarding actual level of bail supervision provided to Brontë and other defendants
  2. Bail officers be trained in administering basic suicidality assessments
  3. Consideration be given to funding 48-hour turn-around bail assessment reports for those applying for bail or bail variations
  4. ACT Health consider what input it can provide to bail assessment reports from a policy perspective
Full text
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Source and disclaimer

This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.

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