Findings&recommendationsdrury baxter
Deceased
James Llewellyn Drury
Demographics
34y, male
Date of death
2009-03-15
Finding date
2011-04-04
Cause of death
Asphyxiation by hanging
AI-generated summary
James Llewellyn Drury, 34-year-old Aboriginal person with transgender identification, died by hanging in Metropolitan Remand Centre, Silverwater on 15–16 March 2009 while in custody awaiting trial. Despite vulnerability factors (Aboriginal descent, gender identity, custody-related stress), comprehensive screening by police and Corrective Services staff found no suicide risk indicators. Fellow inmates reported no concerning behaviour. The coroner found the death was intentional self-harm and concluded no reasonable preventive measures could have averted it. Departmental policies on transgender management were substantially complied with. The sole recommendation required recording 'knock-up' emergency facility usage to improve investigation of future custody deaths. This case reflects the limitations of static suicide screening instruments in identifying acute psychological crises in custodial settings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Contributing factors
- Incarceration-related stress and anxiety
- Access to materials that could be fashioned into ligature
Coroner's recommendations
- Recording of 'knock-up' emergency facility usage by inmates and officer responses, with recordings retained for an appropriate period to enable investigation of future custody deaths
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