Demographics
28y, male
Date of death
2020-01-19
Finding date
2023-08-16
Cause of death
neck compression from hanging
AI-generated summary
SH, a 28-year-old man, died by hanging in Cessnock Correctional Centre after seven weeks in custody. He was assessed at intake as having no self-harm risk and cleared for normal cell placement. During custody, he became distressed about relationship concerns and missing his daughters, expressing suicidal ideation to family members on 16 January. His transfer to maximum security on 17 January following alleged escape plan comments may have worsened his psychological state. On 19 January, he was moved to a cell without functioning lights after the knock-up alarm malfunctioned. His partner's cancelled visit that morning appeared to trigger acute hopelessness. Clinical lessons include: improving mental health screening processes; enabling family access to raise welfare concerns; developing protocols for cells with safety concerns; and considering impact of security transfers on vulnerable inmates.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
40y · Male·Unascertained
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Corey Desmond Devree, aged 41, died by suicide in Bunbury Regional Prison on 14 October 2024 through ligature compression of the neck and a self-inflicted stab wound to the chest. Key clinical and systemic lessons includ…
36y · Male·Drowning
Gary Dale Sargeant, a 36-year-old Royal Australian Air Force member, died by drowning after absconding from Edinburgh Health Centre during an acute mental health crisis. Critical clinical failures included: a clinical ps…
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