Deceased
SB
Demographics
38y, male
Date of death
2017-04-02
Finding date
2020-12-11
Cause of death
asphyxiation by ligature
AI-generated summary
A 38-year-old man remanded in custody died by hanging in his prison cell. He faced serious criminal charges and had raised mental health concerns with prison clinicians, being prescribed antidepressants and antipsychotics. The coroner found his psychiatric and psychological care appropriate overall, though documentation was brief. Key failures included: no mechanism to share psychologist assessments with psychiatrists; the psychiatrist was unaware of recent suicidal ideation disclosed to a psychologist; and the psychologist was not provided all of Dr B.'s clinical notes. While the coroner noted green card status could have been considered after 30 March, experts agreed this was not clearly mandated. The inquest identified that more complete information sharing between mental health providers, and earlier documentation of suicidal ideation to all treaters, would have been beneficial for clinical decision-making.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
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