Inquest into the death of Yohan WEPITIYA-GAMAGE
Deceased
Yohan Wepitiya-Gamage
Demographics
19y, male
Date of death
2016-01-22
Finding date
2021-12-09
Cause of death
Hanging
AI-generated summary
Yohan Wepitiya-Gamage, a 19-year-old male remand prisoner with a history of psychosis and substance use, died by hanging in his cell at the Metropolitan Special Programs Centre in January 2016. Critical clinical lessons include: (1) the failure to book a mandatory psychiatric review appointment due to Dr E.'s incomplete documentation on the clinic tracking sheet—the review was due around 21 January but was never scheduled; (2) inadequate record-keeping practices that limited situational awareness during subsequent reviews; (3) the need for robust administrative systems to ensure follow-up appointments are properly booked and tracked. Although Yohan had been assessed as low suicide risk on 24 December 2015 and again on 3 January 2016, there was a deterioration evident to cellmates between 20–22 January (withdrawn, depressed appearance). A formal psychiatric review as originally intended could have identified this change in mental state, though the coroner acknowledged it was not certain the outcome would have differed. Justice Health has since introduced the Darcy Daily Clinic Tracker Sheet to prevent similar administrative failures.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- Administrative error resulting in failure to book mandatory psychiatric review appointment
- Incomplete documentation on clinic daily sheet by treating psychiatrist
- Inadequate record-keeping and handover processes
- Mental health deterioration between 20 and 22 January 2016 not detected by staff
- One-out cell placement providing isolation without close supervision
- Accessible ligature point in cell (window bars)
Coroner's recommendations
- Update the Custodial Mental Health Operations Manual to reflect the introduction and use of the Darcy Daily Clinic Tracker Sheet
Full text
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