Deceased
JS
Demographics
34y, male
Date of death
2020-05-05
Finding date
2023-05-23
Cause of death
Plastic bag asphyxia
AI-generated summary
A 34-year-old man on remand died by plastic bag asphyxia at Shortland Correctional Centre on 5 May 2020, hours before his release on bail. He had disclosed anxiety and depression, made multiple self-referrals for mental health support, and was placed on waiting lists but not seen by a psychiatrist for over 50 days despite policy requiring assessment within 3-15 days. After a cable-tie incident on 3 May suggesting self-harm risk, he was monitored in the clinic. On 5 May, a nurse released him from clinic monitoring to a single cell without personal review, under pressure to free clinic space. He was placed in a one-out cell contrary to initial recommendations for group placement due to miscommunication about Health Problem Notification Forms. Key failures included systemic delays in mental health care, inadequate nursing assessment before release, and unclear cell placement protocols. The coroner found the death was intentionally self-inflicted but highlighted systemic failures in mental health provision, resource constraints, and workplace pressures affecting clinical decision-making.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
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