Deceased
EJJ
Demographics
39y, male
Coroner
Decision ofJudge Grahame
Date of death
2023-02-16
Finding date
2026-04-01
Cause of death
Hanging
AI-generated summary
A 39-year-old man died by hanging on 16 February 2023 at his home in St Marys, NSW. His mother requested a police welfare check at 8:40pm after he posted a suicide note on Facebook at 2:30pm. Police attended twice (11pm on 16 February and 8am on 17 February) but did not enter the premises, believing he was likely away. Autopsy confirmed death occurred shortly after the Facebook post, likely 2-3pm on 16 February. The coroner found police actions were reasonable given available information, though noted that Senior Constable Hansen should have called the mother back for additional information. Key systemic issues identified: understaffing at Nepean PAC leading to unanswered phone calls, lack of centralised mental health triage for police welfare check calls, and limited co-responder models. The coroner endorsed rolling out co-responder models like those in the UK to improve responses to mental health crises.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.
Specialties
Error types
Drugs involved
Clinical conditions
28y · Male·In keeping with Hanging
A 28-year-old man with a history of depression, anxiety, and previous self-harm died by hanging during a police response to a domestic violence incident. Police attended after his sister reported he had breached an ADVO …
Male·Gunshot wounds to the head
This inquest examined deaths of Noah Smith (15) and Wayne Smith (58) on 1 June 2023. Wayne had 20-year history of chronic depression and suicidal ideation, including severe crisis in May 2020 with suicide plans. He recov…
48y · Male·cardiac arrhythmia which occurred in the context of physical exertion and hypoxi…
Phillip Walton, a 48-year-old with schizophrenia well-managed on clozapine for nearly 20 years, suffered an acute psychotic episode likely precipitated by cannabis use at a circus. After aggressive behaviour requiring po…
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.
Content may be incomplete, reformatted, or summarised. Some material may have been redacted or restricted by court order or privacy requirements. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction — report an inaccuracy here.