Coleman, Randall John

Contributing factors

• Deliberate ingestion of strychnine
• Failure to complete health and medication assessment form at watchhouse admission
• Depression and multiple psychosocial stressors
• Undiagnosed or inadequately managed anger management issues
• Escalating domestic violence
• Inability to access children due to family law proceedings
• Financial stress and property litigation
• Repeated police custody and transfers between facilities
• Patient denial of strychnine ingestion on hospital admission delaying initial diagnosis
• Concealment of suicidal intent despite earlier mental health contact

Coroner's recommendations

1. Allocate resources to enable more effective monitoring of prisoners at Kingaroy police station, noting the additional burden of managing increased prisoner numbers during District Court circuits without a designated watchhouse keeper
2. Prioritise funding for the planned new Kingaroy police and watchhouse facility
3. Consider heightened awareness of suicide risk in police custody when bail is refused, particularly when prisoners have multiple stressors
4. Consider whether Department of Corrective Services-style risk assessment procedures for suicide could be implemented for remanded prisoners in police custody, with appropriate expert personnel
5. Ensure completion of health, medication and personal assessment forms at watchhouse admission, with clear delegation of responsibility when the admitting officer must leave the station
6. Consider systematic screening for elevated suicide risk when prisoners are transferred between facilities or when significant new stressors are identified (e.g. removal of children, bail refusal)
7. Ensure mental health referral information and suicide risk indicators from Child Safety Officers and other agencies are clearly communicated to custodial staff in terms that identify specific risks