Deceased
Mr S
Demographics
57y, male
Date of death
2018-01-15
Finding date
2024-12-12
Cause of death
Hanging
AI-generated summary
A 57-year-old male inmate died by hanging at Long Bay Correctional Centre in January 2018. Although he had been psychiatrically assessed as experiencing major depression with psychotic features and was recommended by a psychiatrist for placement in a two-occupant cell as suicide risk mitigation, he was placed alone due to administrative miscommunication. A reception officer misinterpreted a Health Problem Notification Form, causing the two-out cell recommendation to be disregarded. The coroner found mental health care provided was appropriate, though the error in cell placement was significant. Clinical lessons include the importance of clear communication systems between health and custodial staff, proper escalation of suicide risk assessments, and explicit documentation of recommendations in all relevant systems. The inquest identified systemic failures in translating health recommendations into custodial practice, leading to post-incident reforms in staff training and form redesign.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
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