Barker, Jeremy Dylan
Deceased
Jeremy Dylan Barker
Demographics
27y, male
Coroner
Barnes
Date of death
2007-10-21
Finding date
2010-10-08
Cause of death
Hanging
AI-generated summary
Jeremy Barker, a 27-year-old man with bipolar disorder, recent suicide attempts, and explicit stated intention to hang himself, was admitted to Arthur Gorrie Correctional Centre's medical unit for observation as an 'at-risk' prisoner. Four days later, he died by hanging using a bed sheet attached to exposed window bars in the toilet. Critical failures included: housing an acutely suicidal patient in an area with accessible hanging points despite prior staff warnings about this risk; inadequate physical observation (required 15-minute checks were not performed in person after 2:00pm, relying instead on CCTV); management's failure to respond to repeated staff concerns about unsupervised toilet access and exposed bars; and insufficient monitoring during the critical period when the patient was distressed and writing a suicide note. The coroner identified this as preventable, resulting from both individual and systemic failures in risk management and observation protocols.
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Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- Inadequate observation of at-risk prisoner; required 15-minute physical checks not performed after 2:00pm
- Housing suicidal patient in medical unit with accessible hanging points (exposed window bars)
- Prior staff warnings about toilet risks ignored by management
- Failure to remove ligature materials (bed sheets) from at-risk prisoner
- Reliance on CCTV rather than required physical observation
- Management inaction despite July and August 2007 emails from CSOs about hanging risks
- Insufficient psychiatric monitoring during acute mental health crisis
- Delayed pharmaceutical stabilisation following admission
Coroner's recommendations
- Removal or covering of exposed bars and hanging points in correctional facility medical units
- Reinforcement of observation policies requiring physical in-person checks rather than CCTV monitoring for at-risk prisoners
- Enhanced management response protocols to staff safety concerns about suicide risks
- Additional rostering of correctional officers when prisoners requiring observation are present
- Mandatory training for correctional officers in mental illness recognition and management
- Regular review of hanging points throughout correctional facilities
Full text
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