A 42-year-old male prisoner with a history of alcohol dependence, PTSD, and epilepsy died by intentional hanging in Cessnock Correctional Centre. Mental health assessments on reception and during detention found no suicidal ideation or self-harm history, and he was cleared for normal cell placement. He displayed no concerning behaviour in the hours before death. The coroner found that responsible officers in Corrective Services and Justice Health appropriately assessed self-harm risk and that nothing warranted intervention. The death was deemed unforeseeable. The coroner noted that correctional officers lacked 911 rescue tools at the time of discovery, though this caused no harm given the prolonged nature of death. The case highlights the challenge of identifying suicide risk in prisoners with substance dependence and trauma histories.
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Corrective Services NSW to ensure all uniformed officers whose duties include inmate contact are issued with a 911 rescue tool at the commencement of duty
The 911 rescue tool must be carried at all times throughout the officer's shift
Local operating procedures regarding the issue and return of the 911 rescue tool for each officer shift are to be implemented by General Managers at correctional centres
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