Stanford, Tony John
Deceased
Tony John Stanford
Demographics
36y, male
Date of death
2006-09-19
Finding date
2009-07-03
Cause of death
Hanging
AI-generated summary
Tony Stanford, a 36-year-old remand prisoner with depression and a history of suicide attempt, died by hanging in his cell at Arthur Gorrie Correctional Centre on 19 September 2006. He was on a risk management plan requiring two-hourly observations due to low-risk suicide concerns but was not observed between 5:30pm and 9:00pm on the day of death due to systemic issues with shift handover timing and prisoner location communication. Mental health assessment and treatment were found reasonable and appropriate. However, a critical gap in observation compliance was identified due to procedures where night-shift staff were unaware of at-risk prisoner locations until first headcount. The coroner found mental health decisions defensible but systemic operational failures in observation practices, leading to multiple remedial measures including staff assignments, cell inspections, and unit accommodation changes.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Clinical conditions
Contributing factors
- Failure to comply with two-hourly observation schedule for at-risk prisoner
- Systemic defect in observation procedures during night shift handover
- Delay in first headcount of evening due to early lock-down practice
- Night shift staff not informed of at-risk prisoner locations
- Delayed reception processing and medical unit congestion
- Prisoner incident during shift creating competing demands on staff
Coroner's recommendations
- Unit lock-down should not commence before 5:45pm to improve compliance with observation schedules
- All prisoners subject to observation requirements to be listed and handed to Correctional Manager Operations by 4pm daily
- Prisoners requiring two-hourly observations to be accommodated in Unit W1 overnight (with W1 overflow to medical unit with CCTV surveillance)
- Dedicated staff assigned to perform required observations as primary role, with enforcement and review by management
- Variation of assessment levels only by Risk Assessment Team or General Manager level
- CCTV monitoring in Unit W1 with dedicated officer monitoring split-screen footage
- Daily cell searches and prisoner searches for at-risk prisoners
- Special audit of shelf units to identify and remedy defects that could be utilised for hanging
- Reception area to remain open on night shift with extra staff deployed to reduce delays in prisoner processing
Full text
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