Inquest into the death of PF
Deceased
PF
Demographics
45y, male
Date of death
2023-09-17
Finding date
2025-07-24
Cause of death
Hanging
AI-generated summary
PF, aged 45, died by hanging in custody at South Coast Correctional Centre following bail refusal and adverse legal advice. The coroner found his death was intentional self-harm. Although PF had a significant history of self-harm attempts and suicidal ideation, the coroner determined that reception, intake screening, and classification processes were reasonable despite limitations in detail and the non-psychological training of staff. Risk of suicide was fluid and not acutely identifiable in the days before death. The cancelled psychology appointment on 13 September due to COVID-19 lockdown may have been a 'circuit breaker' but this was uncertain. No systemic failures by correctional or justice health services were identified, and the one-out cell placement was appropriate given PF's PTSD and prior assault trauma. No recommendations were made.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Contributing factors
- bail refusal on 2 August 2023
- adverse legal advice regarding sentence prospects received 11 September 2023
- deteriorating mental health
- cancelled psychology appointment on 13 September 2023 due to COVID-19 lockdown
- history of self-harm and suicidal ideation
- one-out cell placement
- previous institutional sexual abuse and trauma
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Source and disclaimer
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