Findings into the death of P
Deceased
P
Demographics
72y, male
Date of death
2017-04-22
Finding date
2021-10-21
Cause of death
Hanging
AI-generated summary
A 72-year-old male inmate at Long Bay Correctional Centre died by hanging in April 2017. He had a documented history of depression managed with antidepressant medications, and his medication (mirtazapine) was adjusted twice in the months before his death without face-to-face psychiatric review—only via telephone consultation between nursing staff and an on-call psychiatrist. The coroner found that medical care was appropriate and did not identify deficiencies. However, the inquest prompted development of Guidelines for Psychotropic Medications 2020 recommending face-to-face reviews within six months of medication adjustments. The case highlights the tension between custody care standards and community practice, and the critical importance of removing hanging points from correctional facilities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Recent additional criminal charges with bail refusal affecting parole prospects
- Mood deterioration following new charges
- Medication review conducted without face-to-face psychiatric assessment
- Remote telephone consultation model for medication adjustment
- Availability of hanging points in cell (window bars with ligature anchor)
- Mental health care provided through nurse-led model with remote specialist consultation
Coroner's recommendations
- Maintain commitment to removing hanging points from cells in Long Bay Correctional Centre and ensure all cells in prisons throughout NSW conform to similar safety standards
- Develop clear guidelines with timeframes for face-to-face medical reviews following medication increases (addressed through Guidelines for Psychotropic Medications 2020, which specify face-to-face review within six months of medication adjustments where compliant patient, clinically appropriate change, recent assessment, and metabolic monitoring ordered)
Full text
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 —