Deceased
AB
Demographics
34y, male
Date of death
2013-08-30
Finding date
2015-06-16
Cause of death
Hanging
AI-generated summary
A 34-year-old man died by suicide by hanging whilst on remand in a correctional facility. He had disclosed his father's suicide 12 years earlier during initial assessment, but was not identified as self-harm risk. In the weeks before his death, telephone records showed escalating distress about potential lengthy sentences, including explicit statements about not surviving life imprisonment. A cellmate noted depression and comments about family suicide. The coroner found screening and cell placement appropriate and protocols were followed, but noted the deceased's mother was unaware of avenues to report welfare concerns. Key clinical lessons: suicide risk assessment in custody must incorporate disclosed family history of suicide and explicit statements about inability to survive sentences; family concerns should trigger proactive welfare review; information about support pathways should be actively disseminated to families, not merely made available.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
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36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
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Martin Carl Quiterio, a 59-year-old man with longstanding schizophrenia and suspected autism spectrum disorder, died on 3 January 2024 when he jumped from the 14th floor of a car park in West Perth. He had been discharge…
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