Inquest into the death of GB
Deceased
GB
Demographics
38y, male
Date of death
2011-09-26
Finding date
2014-05-21
Cause of death
asphyxiation due to hanging
AI-generated summary
A 38-year-old remand prisoner with a long history of drug dependency died by asphyxiation from hanging in his cell at a metropolitan remand centre in September 2011. He had been assessed multiple times by the Risk Intervention Team and Justice Health staff following an initial suicide statement, and was appropriately managed with medication and close monitoring. On the day before his death, he appeared settled, denied suicidal ideation, and his risk status was downgraded. He died the following morning. The coroner found that suicide is unpredictable and that the departmental protocols were appropriately executed. While a correctional officer failed to follow protocol when responding, this would not have altered the outcome as the prisoner was beyond resuscitation. No systemic failures were identified.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- history of drug dependency
- use of ice at time of arrest
- withdrawal from drugs in custody
- previous suicidal ideation
- unpredictability of suicide
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