Coronial
NSWother

Inquest into the death of PE

Deceased

PE

Demographics

53y, male

Coroner

Decision ofJudge Grahame, Deputy State Coroner

Date of death

2024-02-03

Finding date

2026-05-01

Cause of death

Hanging

AI-generated summary

PE, aged 53, died by hanging in Parklea Correctional Centre on 3 February 2024, four days after entering custody for the first time on remand. The coroner found PE's death was self-inflicted at a time of emotional turmoil. Intake screening by both nursing (RSA) and correctional staff (ISQ) was adequately performed and did not identify him as at imminent risk. However, the coroner identified that the lack of contact with PE's supportive wife—attributable to delays in activating his phone account and restrictive telephone policies for remand inmates—likely contributed to his declining mental health. The cell contained multiple hanging points inconsistent with modern anti-ligature design. The coroner made recommendations addressing: (1) increasing free phone calls for unsentenced inmates through rate negotiation and automatic phone credit on reception; and (2) reviewing policies in light of declining landline usage. The screening processes themselves were considered appropriate despite the tragic outcome.

AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes. Report an inaccuracy.

Specialties

general practicepsychiatrycorrectional health

Error types

systemdelay

Clinical conditions

situational depressionsuicide

Contributing factors

  • Lack of contact with wife due to delayed phone account activation
  • Restrictive telephone policies for remand inmates
  • Transition to custody for first time with serious criminal charges pending
  • Presence of multiple hanging points in cell
  • Sudden separation from supportive family relationships

Coroner's recommendations

  1. CSNSW is to review COPP 8.2 Inmate Telephones and related phone policies and procedures to consider increasing access to personal telephone calls for unsentenced inmates to either an Australian mobile phone number or landline number (local or national). The review will include consideration of the following initiatives: (a) Immediate renegotiation of call rates to reduce landline and mobile call charge rates for inmates; (b) A centralised processing model for phone numbers and phone money at large remand centres to expedite the activation of inmates' OTS accounts; and (c) Automatic phone account credit for inmates on reception to ensure calls are automatically available upon entry into custody.
  2. CSNSW is to review their phone policies for inmates in the context of the steady decline of landline usage and ownership in Australia. In particular, the feasibility of offering an increased number of free or reduced rate calls to mobile numbers and landlines to all inmates should be investigated and consideration be given to implementation.
Full text

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