Inquest into the death of DP
Deceased
DP
Demographics
52y, male
Date of death
2021-04-04
Finding date
2023-11-16
Cause of death
hanging
AI-generated summary
A 52-year-old man with a history of depression, ankylosing spondylitis, and severe obstructive sleep apnoea died by hanging in custody. He had requested a CPAP machine for over 9 months without receiving one, which he believed exacerbated his depression. The coroner found his mental health was generally appropriately managed but noted that psychiatric review should have been sought when antidepressant treatment proved ineffective. Key failures included: failure to recognise and prescribe his CPAP machine needs (he had only been trialling one, not prescribed), absence of a psychiatric referral despite ongoing depression resistant to GP-level management, policy ambiguities regarding cell checks on public holidays, and delays in accessing specialist respiratory review. The coroner found no single preventable act would have saved his life, but identified systemic improvements needed in custody mental health care, specialist access, and patient communication systems.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- untreated severe obstructive sleep apnoea lasting over 9 months
- depression not responsive to antidepressant monotherapy without psychiatric review
- lack of psychiatric referral despite failed initial treatment and complex psychiatric history
- failure to identify that patient had only trialling prescription, not formal CPAP prescription
- system delay in obtaining specialist respiratory review (9+ months)
- inadequate morning cell check procedures on public holiday
- absence of collateral psychiatric history gathering
- patient frustration with self-referral form system
- serious criminal charges and uncertainty about lengthy incarceration
Coroner's recommendations
- St Vincent's Correctional Health should formalise a policy for acquiring CPAP machines for inmates who require them in custody, including the source and funding of those machines
- St Vincent's Correctional Health should consider enhancing the system of patient self-referral at Parklea Correctional Centre, to include access to appointments via telephone
- The Commissioner Corrective Services NSW should continue to seek additional funding for the program of cell refurbishment, to progress the removal of obvious ligature points from cells in correctional centres as a matter of urgency
Full text
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