Coronial
NSWother

Inquest into the death of WM

Demographics

59y, male

Date of death

2020-04-02

Finding date

2024-03-06

Cause of death

Hanging

AI-generated summary

A 59-year-old man serving a life sentence died by hanging in his segregation cell at Lithgow Correctional Centre on 2-3 April 2020. He had a history of depression, anxiety, and a prior serious self-harm attempt in 2010 requiring hospitalisation. Despite receiving psychiatric care and antidepressant medication (mirtazapine), he was not assessed as requiring close observation in the weeks before death. He appeared accepting of returning to mainstream population when segregation was revoked. Multiple hanging points existed in his cell including a metal grating above the door. While psychiatric support was deemed adequate, the coroner identified concerns about the availability of hanging points in correctional facilities and inadequate removal despite policy breaches (makeshift clothesline visible to staff). The death was self-inflicted but clinical escalation, risk reassessment timing, and environmental safety measures warrant review.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.

Specialties

psychiatryforensic medicinecorrectional health

Error types

system

Drugs involved

mirtazapinemetoprololcarbamazepinelercardipine

Clinical conditions

depressionanxietyhypertensionseizure disorderself-harmprior head injury with craniotomy

Contributing factors

  • History of depression and anxiety
  • Prior self-harm attempt with significant injury in 2010
  • Segregation placement following chest pain evaluation raising escape concerns
  • Multiple hanging points within segregation cell including metal grating above door
  • Policy breach: clothesline and shower curtain supports made from bed sheet material visible to staff but not removed
  • Insufficient hanging point removal across correctional facilities despite ongoing program
  • Social isolation in segregation unit with 22-hour daily confinement
  • Minimal recent contact with family/external support (5 attempted calls in 18 months, only 2 connected)

Coroner's recommendations

  1. Continued implementation of state-wide hanging point removal program in correctional facilities with adequate resourcing
  2. Lithgow Correctional Centre to be prioritised for cell refurbishment program to remove hanging points
  3. Enhanced environmental assessment protocols for inmates in segregation units
  4. Review of psychiatric risk assessment timing and frequency for high-risk inmates, particularly during transitions between custody units
  5. Development of more robust hanging point removal policies with clear enforcement mechanisms
Full text
Official source Archived copy

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Source and disclaimer

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