Coroner's Finding: Samuel Dibley
Deceased
Samuel Dibley
Demographics
23y, male
Date of death
2009-05-23
Finding date
2011-12-13
Cause of death
cerebral hypoxia secondary to strangulation from hanging by belt
AI-generated summary
Samuel Dibley, aged 23, was involuntarily admitted to the Mental Health Unit on 19 May 2009 with cannabis-induced psychosis and suicidal ideation. He was placed in the Low Dependence Unit (LDU) based on risk assessment. Nursing staff provided regular observations; early morning observation found no active suicidal intent. Later that day, he was found hanged by his belt from a hole in his wardrobe door and died from cerebral hypoxia three days later. The coroner found clinical staff acted appropriately and ward-level observation was adequate. However, the case identifies important environmental and procedural improvements: removal of hanging points from mental health units (wardrobe doors have since been removed), and timely police notification for critical incidents to preserve scene evidence and exclude third-party involvement, even when self-harm is suspected.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Drugs involved
Contributing factors
- cannabis-induced psychosis
- acute psychotic episode with paranoia and delusions
- suicidal ideation
- availability of hanging point in wardrobe door
Coroner's recommendations
- NSW Health and NSW Police should develop a protocol governing procedures for investigating critical incidents in NSW hospitals, covering timely police notification, preservation of crime scenes, securing exhibits and documents, identification of witnesses, and taking of witness statements
Full text
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