NSWother

Inquest into the death of David WOTHERSPOON

Deceased

David William Wotherspoon

Demographics

31y, male

Date of death

2013-04-14

Finding date

2017-08-31

Cause of death

Hypoxic encephalopathy caused by neck compression due to hanging

AI-generated summary

David Wotherspoon, a 31-year-old Aboriginal man with schizophrenia, died from hypoxic encephalopathy following hanging in a prison mental health unit. Despite being psychotic and refusing medication, he was not transferred to a specialised mental health facility (MHSU at Silverwater) for three weeks after his treating psychiatrist ordered it. Key clinical failures included: delayed transfer to appropriate specialist care due to administrative error; failure to use Mental Health Act powers to compel medication when he was clearly psychotic and treatment-resistant; inadequate monitoring of a high-risk cell; presence of ligatures despite known self-harm risk; and insufficient staff supervision in the monitoring room. The coroner concluded the delay in transfer to MHSU was a significant omission. Use of Mental Health Act scheduling could have ensured consistent medication compliance in the specialist facility setting.

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

Specialties

psychiatry correctional health emergency medicine intensive care forensic medicine

Error types

system communication delay

Drugs involved

risperidone diazepam buprenorphine morphine midazolam

Clinical conditions

schizophrenia paranoid psychosis polysubstance abuse hepatitis C self-harm suicide attempt hypoxic encephalopathy cerebral hypoxia

Procedures

cardiopulmonary resuscitation intubation mechanical ventilation external examination autopsy

Contributing factors

Delayed transfer to Mental Health Screening Unit despite psychiatrist's order
Administrative failure to complete transfer referral form promptly (6 days delay)
Failure to use Mental Health Act scheduling to compel medication when patient was clearly psychotic and treatment-resistant
Presence of ligatures (pants drawstring) accessible to at-risk inmate
Hanging point in cell not detected during safety inspection
Inadequate monitoring of cell camera during meal distribution
Inadequately trained monitoring room officer
Single officer in monitoring room managing 64 cell camera screens
Inconsistent medication compliance due to refusal of injections and lack of coercive authority
Mental Health Unit at Cessnock not appropriate for acutely psychotic patients
Lack of assertive management of psychiatric deterioration

Coroner's recommendations

Ensure that the Monitor Room Standing Operating Procedure includes a direction that staff initiate effective responses to covered cameras and that control room has primary responsibility for monitoring assessment cells
Instructions should be given as to what matters are to be recorded in the Monitor Room log
Review of NSW Health Policy Directive PD2012_049 on Forensic Pathology – Code of Practice regarding standards for deaths in custody, with consultation of coroners to clarify the balance between invasiveness of autopsy and the circumstances of each case
Corrective Services and Justice Health should develop clearer guidelines for utilization of the Mental Health Act in custodial settings to enable more assertive management of treatment-resistant psychotic prisoners
Ensure prisoners on Risk Intervention Team protocols within Mental Health Units do not have access to ligatures (drawstrings, cords)
Ensure adequate training of monitoring room staff prior to commencing duties
Ensure adequate staffing of monitoring rooms during periods when unit officers are engaged in other duties such as meal distribution

Full text

Official source Archived copy

Related cases

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.

Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.

Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —