Inquest into death of William EPERE
Deceased
William Epere
Demographics
43y, male
Date of death
2019-01-10
Finding date
2022-11-24
Cause of death
Hanging
AI-generated summary
William Epere, aged 43, died by hanging in custody at Dawn de Loas Correctional Centre on 10 January 2019. He had been remanded in custody for 27 days following repeated breaches of a domestic violence order, despite clear mental health deterioration. Although Billy was found to be deceased and unable to be resuscitated, the coroner identified critical systemic failures in the custodial response: the Senior Corrective Officer and two junior officers did not carry the mandatory 911 tool (emergency cutting device), resulting in a 10-minute delay before attempting resuscitation. The coroner emphasised that while these specific failures could not have altered the outcome in this case, proper carrying of the 911 tool and regular scenario-based training on hanging response were essential safeguards that could save lives in future incidents. The findings highlight systemic complacency regarding mandatory safety equipment despite existing clear policies, and the need for regular refresher training among custodial staff.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Procedures
Contributing factors
- Failure of correctional officers to carry mandatory 911 tool in breach of policy
- Delay of approximately 10 minutes before body was cut down due to absence of emergency cutting tool
- Lack of regular scenario-based training for correctional officers on hanging response
- Systemic complacency regarding carrying mandatory safety equipment despite existing clear policies
- Mental health deterioration while in custody, with Billy assessed as low risk but expressing he 'doesn't care anymore'
- Underlying severe depression and anxiety with multiple prior suicidal ideation
- Window of cell blocked by sheet, obscuring initial observation
Coroner's recommendations
- That Corrective Services NSW give consideration to the provisions of ongoing specific practical training on hanging response, and audit individual participation rates annually to ensure attendance
- That Dawn De Loas Correctional Centre give consideration to ensuring compliance with the requirement to carry the 911 tool in accordance with Policy 5.3 Musters, Let-go and Lock in, through specific targeted education and random compliance checks
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