Pittaway, Steven John and Coe, Paul Allen
Deceased
Paul Allen Coe and Steven John Pittaway
Demographics
male
Date of death
2005-06-11, 2005-12-08
Finding date
2007-03-30
Cause of death
Coe: self-inflicted hanging; Pittaway: neck compression due to self-inflicted strangulation
AI-generated summary
Two men died by suicide in Bundaberg Watch House within 7 months. Paul Coe (38) hanged himself using his shirt from a door hinge on 11 June 2005, approximately 25 minutes after officers last physically checked him. Steven Pittaway (46) died by strangulation using a ligature on 8 December 2005, undetected for 80 minutes despite mandatory hourly inspections. Critical failures included: officers conducting prisoner monitoring via CCTV rather than required physical cell inspections, inadequate risk reassessment after significant circumstances changed (Coe denied bail), failure to check police databases revealing prior suicide risk (Pittaway), and unsafe watch house design with accessible hanging points. The coroner found no direct staff culpability but identified systemic failures in policy compliance, supervision, training, and infrastructure that created preventable vulnerabilities.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- failure to conduct mandatory physical prisoner inspections at required intervals
- reliance on CCTV monitoring instead of personal cell inspections
- inadequate reassessment of suicide risk after significant change of circumstances (bail denial for Coe)
- failure to check POLARIS database for suicide risk flags (Pittaway had prior entry indicating suicide risk)
- watch house design with accessible hanging points on door hinges
- inadequate watch house manager supervision and enforcement of OPM requirements
- non-compliance with prisoner inspection procedures by watch house staff
- lack of training and awareness of mandatory inspection requirements among some officers
Coroner's recommendations
- Recommendation 1 – Reassessment after change of circumstances: Watch house staff be directed to have regard to the likely impact of criminal justice decisions on prisoners and to re-assess a prisoner's risk of self harm whenever a negative impact can be anticipated, particularly following bail denial or sentencing.
- Recommendation 2 - Checking of computer indices for sentenced prisoners: Amend the OPM to make clear the responsibility of watch house staff to check all relevant indices (POLARIS) when a prisoner is sentenced and comes into the watch house after having been on bail, not just when transferred from correctional centres.
- Recommendation 3 – Review of the OPM requirement to physically inspect prisoners: Review the requirement to inspect prisoners at intervals no greater than one hour in light of watch house managers' concerns to determine whether the requirements should be amended or enforced. If maintained, remind all watch house managers of the requirements and ensure compliance.
- Recommendation 4 – Elimination of hanging points in the Bundaberg Watch House: Make necessary modifications to eliminate hanging points from cell doors, including electronic door locks (to keep doors closed when not in use), material addition to door hinges, and installation of intercom systems in exercise yards.
Full text
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