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
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Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
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