Coronial
NTother

Inquest into the death of Bird

Deceased

Bird (Paul Wayne Clarke)

Demographics

46y, male

Date of death

2011-01-20

Finding date

2011-11-25

Cause of death

Acute hypoxic brain damage resulting from intentional self-inflicted hanging

AI-generated summary

A 46-year-old male prisoner died from acute hypoxic brain damage following self-inflicted hanging in custody. He had a history of physical health issues including HIV and mental health concerns including anger management difficulties. Despite appropriate mental health assessments, psychological counseling, and medical care provided during his 11-month remand, staff had no specific indicators he would self-harm on that date. The coroner concluded there was nothing to alert custodial or medical staff to prevent his death and praised the exemplary emergency response. This case highlights the challenges of suicide prevention in custodial settings and the limitations of risk assessment when individuals have stated they will self-harm at a time of their choosing.

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

Specialties

psychiatrypsychologyinfectious diseasesgeneral medicineemergency medicine

Clinical conditions

HIV infectionAnger management difficultiesPost-traumatic stress disorder (suspected)Behavioral disturbanceEmotional dysregulation

Procedures

Cardiopulmonary resuscitation

Contributing factors

  • Complex physical health issues including HIV
  • Mental health concerns including underlying anger and emotional dysregulation
  • History of attempting to manipulate situations by feigning self-harm intent
  • Refusal to take anti-retroviral medication from November 2010
  • Frustration with legal case outcome and workers compensation dispute
  • Ability to fashion ligature from bed sheet and access to hanging point

Coroner's recommendations

  1. Design of new prison facility to include state-of-the-art security features with minimal hanging points in cells and recreation areas
  2. Adequate CCTV coverage of areas outside cells in new prison design
  3. Programs and facilities in new prison to occupy prisoners and meet their mental and physical health needs
Full text
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