Demographics
42y, male
Date of death
2014-02-25
Finding date
2017-11-10
Cause of death
hanging
AI-generated summary
A 42-year-old male prisoner died by hanging in a standard cell at Parklea Correctional Centre after receiving news that his relationship was ending. Although he had a 2001 history of depression and a prior suicide attempt documented in Justice Health records, this was not flagged in his February 2014 reception assessment. He denied suicide ideation on intake. Officers could not reasonably have anticipated his suicide from a private phone call where he stated he would "neck himself". The Coroner found his death unforeseeable given available information. The case highlights systemic issues: obvious hanging points (window fixtures, shower rods) remained in standard cells despite years of coronial recommendations. The Coroner emphasised that inmates not previously identified as "at risk" may develop sudden, impulsive suicide plans. Key lesson: environmental modifications to eliminate hanging points are essential suicide prevention measures, and comprehensive physical audits of custodial settings are overdue.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
40y · Male·Unascertained
Nathan James Taylor, aged 40, died in Port Lincoln Prison on 24 March 2022 while in custody pending trial on witness interference charges. He had significant medical history including infective endocarditis with tricuspi…
53y · Male·Hanging
PE, aged 53, died by hanging in Parklea Correctional Centre on 3 February 2024, four days after entering custody for the first time on remand. The coroner found PE's death was self-inflicted at a time of emotional turmoi…
41y · Male·Ligature compression of the neck (hanging) and penetrating sharp force injury (s…
Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
Source and disclaimer
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