Inquest into the death of RD
Deceased
RD
Demographics
70y, male
Date of death
2021-11-26
Finding date
2025-09-10
Cause of death
death by hanging, self-inflicted
AI-generated summary
A 70-year-old man died by hanging in prison while serving a sentence for child sexual offences. He had previously attempted suicide in 2017 when initially charged, and was subsequently treated with antidepressants and psychiatric care, achieving stability. Upon remand in custody in December 2019, Justice Health obtained limited medical records that omitted his psychiatric history, though he self-reported his depression and prior attempt. He was triaged as non-acute, placed on a 12-week waitlist, and assessed as low-intermediate suicide risk. When further sexual charges were laid in November 2021, just days before his parole release, he was refused bail. He began preparing the means of suicide the following day and died on 26 November 2021. The coroner found no failure by CSNSW or Justice Health staff contributed to the death, although there were missed opportunities for intervention including: incomplete medical records obtained at reception, lack of an alert system for past suicide attempts, inadequate response to family concerns about mental health when further charges were mentioned, and absence of a welfare check when he returned from court after bail refusal. The coroner made no critical findings but noted systemic limitations in mental health screening and communication.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Contributing factors
- further sexual offence charges laid days before scheduled parole release
- refusal of bail on new charges
- inadequate medical records obtained at initial intake to custody
- absence of alert system for prior suicide attempts in custody records
- inadequate response to family concerns raised when further charges were pending
- no welfare check following return to prison after bail refusal hearing
- limited mental health monitoring between July 2020 and November 2021
- lack of proactive follow-up after family member expressed concern about mental health impact of new allegations
Coroner's recommendations
- No recommendations were made by the coroner. The coroner explicitly stated 'Nothing in the evidence in this matter lends itself to the making of recommendations pursuant to s 82 of the Act.' However, the coroner noted that CSNSW had already updated its Custodial Operations Policy and Procedure 6.3 Inmate Health Needs to categorise family notifications, rendering any recommendation about that incident unnecessary.
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