Inquest into the death of Fredrick Elrezz
Deceased
Fredrick Elrezz
Demographics
32y, male
Date of death
2020-09-25
Finding date
2026-07-10
Cause of death
Hanging (deliberately self-inflicted)
AI-generated summary
Fredrick Elrezz, 32, died by hanging in segregation at Parklea Correctional Centre on 25 September 2020. Arrested on 1-2 September after stabbing police in an apparent suicide-by-cop attempt, Fred explicitly stated his intention to hang himself in prison. Multiple NSW Police officers heard these statements but failed to report them to the custody manager due to systemic policy gaps requiring only specific officer categories to escalate such information. Consequently, Fred's suicidal ideation was never conveyed to correctional health. At prison reception, Fred falsely denied suicidal thoughts and was cleared for standard placement. The coroner found that had police communicated Fred's intentions, he would have been placed under Risk Intervention Team supervision in the clinic with camera monitoring rather than segregation. While alternative management's preventive effect could not be determined, systemic failures prevented proper assessment and management of his mental health risk. The coroner recommended amending NSW Police procedures to require officers to communicate suicidal statements to custody managers.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Clinical conditions
Contributing factors
- Failure to communicate expressed suicidal intent from NSW Police to custody managers
- Systemic failure: requirement to report suicidal comments limited to specific officer categories
- Inadequate training of officers in custody assist role
- Incomplete mental health screening in police custody
- Inadequate mental health assessment at prison reception
- Non-communication of suicide-by-cop attempt to correctional health staff
- Segregation placement without knowledge of suicide risk
Coroner's recommendations
- Amend NSW Police Force Handbook chapter on Custody and Charge Room and Custody Management Standard Operating Procedures to require any officer who becomes aware (through observation or information from colleagues) of anything indicating a person in custody is at increased risk of self-harm or suicide to either communicate this to the custody manager directly or ensure it has been communicated
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