Inquest into the death of Brenden Montgomery
Deceased
Brenden Montgomery
Demographics
36y, male
Date of death
2020-01-02
Finding date
2022-10-12
Cause of death
Hypoxic Ischaemic Encephalopathy
AI-generated summary
Brenden Montgomery, aged 36, died from hypoxic ischaemic encephalopathy after hanging himself on 30 December 2019 while police were present outside his home. He had a long-standing history of depression and anxiety, previous suicide attempts, and acute distress about potential custody. Police responded to a domestic violence complaint and a suicide concern call. Critical delays occurred due to misinterpretation of an ambiguous threat statement (broadcast as a threat to kill police), leading to a decision to wait for the dog unit before entry. The coroner found that clarifying ambiguous threats before broadcast and direct contact with the emergency caller to assess urgency were lessons that could have changed police response timing. No procedural or clinical errors in medical care, but communication and operational decision-making failures contributed to preventable delay.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Misinterpretation and broadcast of ambiguous threat statement regarding threat to police
- Failure to clarify ambiguous threat before radio broadcast
- Decision to wait for dog unit based on perceived threat to police
- Failure of police to directly contact the emergency caller to assess urgency of self-harm risk
- Acting Sergeant Couldrey's assessment that risk was low after observing Montgomery outside house, despite ongoing suicide threat
- Limited mental health training of responding officers
- Inaccurate COPS system warning regarding edged weapon possession
- Montgomery's fear of custody and previous traumatic jail experience
- Long-standing untreated mental health condition
- Relationship breakdown with partner and issues regarding children
Coroner's recommendations
- Police should clarify ambiguous threats before broadcasting them on police radio to avoid heightening perceived risk and influencing tactical decisions
- Police should consider directly contacting the person making a triple 0 call regarding self-harm to assess the urgency and ongoing nature of the threat, rather than relying solely on radio reports
- NSW Police Commissioner should consider the scenario and police actions in Montgomery's death when considering recent coroner recommendations regarding mental health training for NSW Police Force
- NSW Police Commissioner should review policies and systems relating to the creation, accuracy, and storage of warnings on the police COPS system to ensure warnings are accurate and justified
Full text
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