Demographics
36y, male
Coroner
Decision ofDeputy State Coroner Lee
Date of death
2018-07-10
Finding date
2022-02-18
Cause of death
hanging
AI-generated summary
A 36-year-old man died by hanging on 10 July 2018 after leaving his home in Blacktown, NSW. His partner called Triple Zero after 30 minutes, reporting concern for his welfare and that he was acting strangely, restless, and agitated. NSW Ambulance paramedics attended but could not locate him and marked the incident as 'unable to locate'. The incident was then cancelled by police. Two hours later, a member of the public found the deceased suspended from a tree. The coroner's investigation examined whether improved communication and search procedures between NSW Ambulance and NSW Police could have altered the outcome. Key issues included: NSW Ambulance failed to communicate to police that the deceased was known to frequent a 7-Eleven in Blacktown; police dispatchers did not create an independent 'keep lookout' incident when the patient location was unknown; and confusion existed between agencies about the reasons for police involvement and the implications of NSWA cancellation. The coroner made no finding of preventability but identified systemic communication failures and procedural non-compliance warranting training recommendations.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Clinical conditions
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